Stabilized oxymetazoline formulations and their uses

ABSTRACT

The present invention provides stabilized cream formulations of oxymetazoline and uses thereof. The present invention also provides a method of treating facial erythema associated with rosacea in a patient in need of such treatment, comprising topically administering once or twice daily to the site of erythema on the face of the patient a pharmaceutical composition comprising 0.5%, 1.0% or 1.5% oxymetazoline or a pharmaceutically acceptable salt thereof as the sole active ingredient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/429,873 filed on Feb. 10, 2017, which is a divisional of U.S. patentapplication Ser. No. 14/737,360 filed on Jun. 11, 2015, which claims thebenefit of U.S. Provisional Application Ser. No. 62/010,838 filed onJun. 11, 2014 and U.S. Provisional Application Ser. No. 62/069,624 filedon Oct. 28, 2014, all of which are incorporated by reference herein intheir entirety.

FIELD OF THE INVENTION

The present invention is directed to stabilized cream formulations ofoxymetazoline and uses thereof.

BACKGROUND

Oxymetazoline and its use for the treatment of skin diseases anddisorders, including rosacea, is described in U.S. Pat. Nos. 7,812,049and 8,883,838, the entireties of which are hereby incorporated byreference. Oxymetazoline is an alpha-2 adrenergic agonist currentlybeing investigated for the treatment of the erythematosus component ofrosacea. Due to the high ionic strength of the formulation imparted bythe presence of oxymetazoline, creating a stable, efficacious, andcosmetically elegant formulation is difficult.

Rosacea is a chronic disease most commonly characterized by facialerythema (redness). There are at least four identified rosacea subtypesand patients may have more than one subtype present. The four most wellrecognized subtypes are erythematotelangiectatic rosacea (ETR);papulopustular rosacea; phymatous rosacea; and ocular rosacea. Otherless common forms exist and the signs and symptoms of each subtype arenot unique to that subtype and may overlap or coexist with any of themanifestations of any other subtype. ETR may be characterized bytransient and/or permanent erythema with a tendency to flush and blusheasily and telangiectasias, which in its milder form may resemble orpresent as erythema (redness) and in its more pronounced state maymanifest as discrete visible blood vessels on the surface of the skin.Papulopustular rosacea may be characterized by transient and/orpermanent erythema with papules (red bumps) and pustules (pus filledbumps). Without wishing to be bound by theory, though the papules andother inflammatory lesions (e.g. pustules) of papulopustular rosacea maybe mistaken for acne, it is believed that the papules and pustules ofrosacea are different from the papules and pustules of acne and arisefrom different underlying pathophysiologic processes. Phymatous rosaceamay be characterized by thickening skin, irregular surface nodularities,enlargement of facial areas (e.g. nose and cheeks), erythema andtelangiectasias. Ocular rosacea may be characterized by red, dry andirritated eyes and eyelids. In each subtype, erythema andtelangiectasias of varying degree may be a feature.

Rosacea patients may need topical or oral (systemic) medication toalleviate their distress; however, a patient's skin may be so sensitivethat many products are irritating and, in fact, may exacerbate thesymptoms of rosacea and may cause more redness and discomfort thanpatients can tolerate. Thus, rosacea can be very difficult toeffectively treat and thus may not only be physically distressing butalso psychologically distressing. Accordingly, there is a need for acosmetically and pharmaceutically acceptable therapeutic which addressesthe myriad manifestations of rosacea including, but not limited to, theerythema or redness associated with rosacea and the telangiectasiasassociated with rosacea. Additionally, there is a need for acosmetically and pharmaceutically acceptable therapeutic which addressesthe inflammatory lesions and manifestations associated with rosaceaincluding the papules, pustules and phymas (skin thickening).

There exists a need for improved stabilized cream formulations ofoxymetazoline that are effective and well tolerated after topicaladministration to human patients.

SUMMARY OF THE INVENTION

The present invention provides stabilized cream formulations ofoxymetazoline and uses thereof. The present invention also provides amethod of treating facial erythema associated with rosacea in a patientin need of such treatment, comprising topically administering once ortwice daily to the site of erythema on the face of the patient apharmaceutical composition comprising 0.5%, 1.0% or 1.5% oxymetazolineor a pharmaceutically acceptable salt thereof as the sole activeingredient.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows Treatment Response Over 12 Hours on Day 28 (mITTPopulation)—Twice daily Dosing.

FIG. 2 shows Treatment Response Over 12 Hours on Day 28 (mITTPopulation)—Once daily Dosing.

FIG. 3 shows Cumulative amount of Oxymetazoline versus time plots foreach formulation studied. Each data point represents the mean of sixdeterminations (three determinations each from a single skin donor). Twodonors were studied.

Note: For both FIGS. 1 and 2, a treatment response was defined as a≥2-grade decrease (improvement) from baseline on both Clinician'sErythema Assessment and SSA=Subject Self-Assessment of Erythema.

DETAILED DESCRIPTION OF THE INVENTION

Oxymetazoline HCl is an alpha-2 adrenergic agonist currently beinginvestigated for the treatment of the erythematosus component ofrosacea. Due to the high ionic strength of the formulation imparted bythe presence of oxymetazoline, creating a stable, efficacious, andcosmetically elegant formulation is difficult. Provided herein is aunique, stable formulation composition that facilitates delivery ofoxymetazoline into and through the skin. Formulation compositiondisclosed comprises the following unique properties:

-   -   1) Complex oil phase (multiple excipients with varied        physical/chemical properties and high concentration of about        23%) and an ionic API (oxymetazoline). The combination of a        complex oil phase and ionic API factors pose an unique challenge        to develop a physically stable, efficacious formulation.    -   2) Complex oil phase comprises a minimum viscosity. An oil phase        with a minimum viscosity is required to support stabilizing the        cream.    -   3) A complex oil phase that supports increased oxymetazoline        flux (and therefore greater expected efficacy) relative to gel        and creams with simple or no oil phase.

As provided herein, the terms “therapeutically effective” or “effective”may be used interchangeably and refer to an amount of a therapeuticcomposition of embodiments of the present invention (e.g., a compositioncomprising oxymetazoline). For example, a therapeutically effectiveamount of a composition is an amount of the composition, andparticularly the active ingredient, such as oxymetazoline, thatgenerally achieves the desired effect.

A “therapeutically effective amount” or “effective amount” of acomposition is an amount necessary or sufficient to achieve the desiredresult. The activity contemplated by the embodiments herein includesmedically therapeutic and/or prophylactic treatment, as appropriate. Thespecific dose of a compound administered according to this invention toobtain therapeutic and/or prophylactic effects will, of course, bedetermined by the particular circumstances surrounding the case,including, for example, the compound administered, the route ofadministration, and the condition being treated. However, the effectiveamount administered can be determined by the practitioner ormanufacturer or patient in light of the relevant circumstances includingthe condition to be treated, the choice of compound to be administered,and the chosen route of administration, and therefore, the above dosageranges are not intended to limit the scope of the invention in any way.A therapeutically effective amount of the compound of embodiments hereinis typically an amount such that when it is administered in aphysiologically tolerable excipient composition, it is sufficient toachieve an effective systemic concentration or local concentration in oron the tissue to achieve the desired therapeutic or clinical outcome.

The terms “treat,” “treated,” or “treating” as used herein refers totherapeutic treatment and/or prophylactic or preventative measures,wherein the object is to prevent or slow down (lessen) an undesiredphysiological condition, disorder or disease, or to obtain beneficial ordesired clinical results. For the purposes of this invention, beneficialor desired clinical results include, but are not limited to, alleviationof symptoms; diminishment of the extent of the condition, disorder ordisease; stabilization (i.e., not worsening) of the state of thecondition, disorder or disease; delay in onset or slowing of theprogression of the condition, disorder or disease; amelioration of thecondition, disorder or disease state; and remission (whether partial ortotal), whether detectable or undetectable, or enhancement orimprovement of the condition, disorder or disease. Treatment includeseliciting a clinically significant response without excessive levels ofside effects.

As used herein, the term “consists of” or “consisting of” means that theformulation includes only the elements, steps, or ingredientsspecifically recited in the particular claimed embodiment or claim.

As used herein, the term “consisting essentially of” or “consistsessentially of” means that the only active pharmaceutical ingredient inthe formulation or method that treats the specified condition (e.g.erythema or redness associated with the particular disease to betreated) is the specifically recited therapeutic in the particularembodiment or claim.

The term “about” as used herein includes a 5%, 10%, 20%, 30%, 40%, 50%,60%, 70%, 80%, 90% or 100% deviation above or below the given value. Foran amount of an active ingredient in a pharmaceutical formulationprovided herein, the term “about” refers to a 5%, 10%, 20% or 30%deviation above or below the given value. For example, an amount of anactive ingredient in a pharmaceutical formulation given as “about 1.0%w/w” includes a range of 0.95% to 1.05% w/w, 0.9% to 1.1% w/w, 0.8% to1.2% w/w, or 0.7% to 1.3% w/w. For an amount of an inactive ingredientor excipient in a pharmaceutical formulation provided herein, the term“about” refers to a 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or100% deviation above or below the given value. One skilled in the art isable to determine reasonable deviations based on the specific valueevaluated.

As used herein, the term “erythema” refers to any redness of the skindue to hyperemia, congestion of the vasculature or dilation of thevasculature of the skin and its surrounding structures. Erythema mayoccur in many conditions of the skin including, but not limited to,rosacea and symptoms associated with rosacea, including, for example,papules, pustules, phymas (skin thickening), telangiectasias or erythemaassociated with rosacea, other skin erythemas, telangiectasias, purpuraor the like, and other manifestations associated therewith; otherinflammatory conditions of the skin as provided herein.

The term “salt(s)”, as employed herein, denotes acidic salts formed withinorganic and/or organic acids, as well as basic salts formed withinorganic and/or organic bases. In addition, when a compound containsboth a basic moiety, such as, but not limited to a pyridine orimidazole, and an acidic moiety, such as, but not limited to acarboxylic acid, zwitterions (“inner salts”) may be formed and areincluded within the term “salt(s)” as used herein. Pharmaceuticallyacceptable (i.e., non-toxic, physiologically acceptable) salts arepreferred, although other salts are also useful. Salts may be formed,for example, by reacting the free form of a compound with an amount ofacid or base, such as an equivalent amount, in a medium such as one inwhich the salt precipitates or in an aqueous medium followed bylyophilization.

Exemplary acid addition salts include acetates, ascorbates, benzoates,benzenesulfonates, bisulfates, borates, butyrates, citrates,camphorates, camphorsulfonates, fumarates, hydrochlorides,hydrobromides, hydroiodides, lactates, maleates, methanesulfonates,naphthalenesulfonates, nitrates, oxalates, phosphates, propionates,salicylates, succinates, sulfates, tartrates, thiocyanates,toluenesulfonates (also known as tosylates) and the like. Additionally,acids which are generally considered suitable for the formation ofpharmaceutically useful salts from basic pharmaceutical compounds arediscussed, for example, by P. Stahl et al, Camille G. (eds.) Handbook ofPharmaceutical Salts. Properties, Selection and Use. (2002) Zurich:Wiley-VCH; S. Berge et al, Journal of Pharmaceutical Sciences (1977)66(1) 1-19; P. Gould, International J. of Pharmaceutics (1986) 33201-217; Anderson et al, The Practice of Medicinal Chemistry (1996),Academic Press, New York; and in The Orange Book (Food & DrugAdministration, Washington, D.C. on their website). These disclosuresare incorporated herein by reference thereto.

Exemplary basic salts include ammonium salts, alkali metal salts such assodium, lithium, and potassium salts, alkaline earth metal salts such ascalcium and magnesium salts, salts with organic bases (for example,organic amines) such as dicyclohexylamines, t-butyl amines, and saltswith amino acids such as arginine, lysine and the like. Basicnitrogen-containing groups may be quarternized with agents such as loweralkyl halides (e.g. methyl, ethyl, and butyl chlorides, bromides andiodides), dialkyl sulfates (e.g. dimethyl, diethyl, and dibutylsulfates), long chain halides (e.g. decyl, lauryl, and stearylchlorides, bromides and iodides), aralkyl halides (e.g. benzyl andphenethyl bromides), and others.

All such acid salts and base salts are intended to be pharmaceuticallyacceptable salts within the scope of the invention and all acid and basesalts are considered equivalent to the free forms of the correspondingcompounds for purposes of the invention.

In an especially preferred embodiment, the pharmaceutically acceptablesalt is a hydrochloride salt, i.e., the compound of the presentcomposition is oxymetazoline hydrochloride.

In some embodiments, the stabilized cream formulations provided hereinmay be used in a method of treating a skin condition, including, but notlimited to, rosacea, including, for example, erythematotelangiectaticrosacea, papulopustular rosacea, phymatous rosacea, ocular rosacea orcombinations thereof; and symptoms associated with rosacea, including,for example, papules, pustules, phymas (skin thickening),telangiectasias or erythema associated with rosacea, other skinerythemas, telangiectasias, purpura or the like, and othermanifestations associated therewith; other inflammatory conditions ofthe skin including, but not limited to, keratosis pilaris, lupusmiliaris disseminatus faciei, eczema, dermatitis, such as contactdermatitis, atopic dermatitis, seborrheic dermatitis, nummulardermatitis, generalized exfoliative dermatitis, stasis dermatitis,neurodermatitis, lichen simplex chronicus, xerosis and xeroticdermatitis, dyshidrosis and dyshidrotic dermatitis, asteatoticdermatitis or other conditions characterized by sensitive skin or adisturbance of the epidermal barrier; disorders characterized by rough,dry, cracked or fissured skin, disorders characterized by hyperkeratoticskin such as keratodermas and ichthyosis and ichthyosiform dermatoses;disorders of hair follicles and sebaceous glands, such as acne, perioraldermatitis, and pseudofolliculitis barbae; disorders of sweat glands,such as miliaria, including, but not limited to, miliaria crystallina,miliaria rubra, miliaria profunda, miliaria pustulosa; sunburn, chronicactinic damage, poikiloderma, radiation dermatitis, actinic purpura(“solar purpura”); other inflammatory dermatoses, reactions andconditions of the skin, including, but not limited to, psoriasis, drugeruptions, erythema multiforme, erythema nodosum, and granulomaannulare; diseases and conditions characterized by bleeding or bruisingsuch as petechiae, ecchymosis, purpura and the like including anyaccumulation of blood in the skin due to vascular extravasation,irrespective of size or cause, bleeding or bruising due to any skininjury which may include any trauma including surgical or proceduraltrauma; infection, inflammatory dermatoses or inflammation due to anycause or combinations thereof comprising administering a creamformulation provided herein.

Example 1: Stabilized Oxymetazoline HCl Cream Formulations

The stabilized cream formulations of oxymetazoline HCl have thefollowing unique properties:

-   -   1) Complex oil phase (multiple excipients with varied        physical/chemical properties and high concentration of about        23%) and an ionic API (oxymetazoline). The combination of a        complex oil phase and ionic API factors pose an unique challenge        to develop a physically stable, efficacious formulation.    -   2) Complex oil phase comprises a minimum viscosity. An oil phase        with a minimum viscosity is required to support stabilizing the        cream.    -   3) A complex oil phase that supports increased oxymetazoline        flux (and therefore greater expected efficacy) relative to gel        and creams with simple or no oil phase.

Each of the tested formulations contain a complex oil phase (multipleexcipients with varied physical/chemical properties and highconcentration of about 23%) and an ionic API (oxymetazoline). Thecombination of a complex oil phase and ionic API posed a uniquechallenge to develop a physically stable formulation that maintainedgood efficacy at the given concentration of API. The formulations ofTable 1 below were found to have good physical stability therebypredicting good shelf life as a commercial topical drug product.

TABLE 1 Exemplary formulations evaluated for physical stability Example1 2 3 4 Function Ingredient % w/w Active Oxymetazoline HCl 1.5 1.5 1.00.5 Preservative Methylparaben 0.2 0.2 0.2 0.2 Propylparaben 0.05 0.050.05 0.05 Phenoxyethanol 0.8 0.8 0.8 0.8 Buffer Sodium citrate,dihydrate 0.3 0.7 0.3 0.3 Citric acid, anhydrous 0.219 — 0.219 0.219Chelating Agent Edetate, disodium 0.01 — 0.01 0.01 Antioxidant BHT 0.05— 0.05 0.05 Oil Phase Lanolin, anhydrous 2 — 2 2 Medium chain 7 2 7 7triglycerides Diisopropyl adipate 7 7 7 7 Oleyl alcohol 7 — 7 7 SolventPEG-300 4 2 4 4 Emulsifier Stearic Acid — 2 — — Emulsifying wax — 5 — —PEG-6/PEG-32/Glycol 8 — 8 8 Stearate (Tefose-63) Cetostearyl alcohol 8 —8 8 Ceteareth-6/Stearyl 2 1 2 2 alcohol (Cremophor A6) Ceteareth-25 2 12 2 (Cremophor A25) Vehicle Purified water QS QS QS QS

Formulations 1, 3 and 4 of Table 1 each comprises a thickened cream withviscosity around 200,000-600,000 cPs. Formulation 2 has a reduced oilphase composition and different emulsifiers, which resulted in aformulation of significantly lower viscosity.

A complex oil phase supports increased oxymetazoline flux relative togel and creams with simple or no oil phase as shown in Table 1a.Formulations in Table 1b-1c describe cream formulations comprisingsimplified oil phase systems (Table 1b) and emulsified gel formulationswith high solvent phase systems (Table 1c).

TABLE 1a Oxymetazoline cream control formulation Formulation Number Oxycream control Function Ingredient % w/w Active Oxymetazoline HCl 0.5Preservative Methylparaben 0.2 Propylparaben 0.05 Phenoxyethanol 0.8Buffer Sodium citrate, dihydrate 0.3 Citric acid, anhydrous 0.219Chelating Agent Edetate, disodium 0.01 Antioxidant BHT 0.05 Oil PhaseLanolin, anhydrous 2 Medium chain triglycerides 7 Diisopropyl adipate 7Oleyl alcohol 7 Solvent PEG-300 4 Emulsifier PEG-6/PEG-32/GlycolStearate 8 (Tefose-63) Cetostearyl alcohol 8 Ceteareth-6/Stearyl alcohol2 (Cremophor A6) Ceteareth-25 (Cremophor A25) 2 Vehicle Purified waterQS

TABLE 1b Oxymetazoline cream formulations with simplified oil phasesystems Cream Formulations D1 F1 Function Components Amt (wt %) API Oxy0.5 0.5 Emulsifier Tefose 63 8 8 Cetostearyl alcohol 5 0 Cetyl alcohol 55 Emulsifying wax 0 3 Solvent Glycerin 0 4 Oil Phase Isopropyl palmitate0 2 Labrafil M1944 CS 5 0 Preservative Methyl paraben 0.2 0.2Phenoxyethanol 0.8 0.8 Propyl paraben 0.05 0.05 Buffer Citric acid 0.740.74 Vehicle Water QS 100% QS 100%

TABLE 1c Oxymetazoline gel formulations with solvent phase system GelFormulations 1 2 3 11 Function Components Amt (wt %) API Oxy 0.5 1.5 0.50.5 Preservatives Methyl paraben 0.2 0.2 0.2 0.2 Propyl paraben 0.020.02 0.02 0.02 Phenoxyethanol 1 1 — — Solvent Glycerol 5 5 — —Transcutol 5 5 10 10 Ethanol 5 5 — — Emulsifier Lutrol F127 1 1 — —Antioxidant EDTA 0.03 0.03 0.03 0.03 Thickeners Carbopol 974 2 — — 2Sepineo P 600 — — 4 — HEC HHX — 1 — — Buffer NaOH/Citric ps pH ps pH pspH 4.75 ps pH 4.75 4.75 4.75 Emollient Cyclomethicone 13 13 — — VehicleBuffered water QS 100% QS 100% QS 100% QS 100% (Phosphate/citrate)

Example 2: In Vitro Study

Methodology

Human cadaver skin from the back or leg region was mounted on adiffusion chamber. Skin samples from two donors were evaluated. Skinsamples were applied stratum corneum side up on a Franz diffusion cell.Formulation was applied in a defined volume to the skin sample andgently rubbed into the skin with a glass stir rod. The receptor chamberof the diffusion cell was filled with phosphate buffered saline. At eachtimepoint the entire receptor chamber was emptied and replaced withfresh buffer. The aqueous samples were analyzed for oxymetazoline andpresented as a cumulative amount versus time plot in FIG. 1 below.

Results

FIG. 3 presents the oxymetazoline concentration in the receptor fluid asa function of time. The results show that the oxymetazoline creamcontrol formulation comprising a complex oil phase produces the highestpermeation. Results from this skin penetration study show the unexpectedcombination of the excipients in the oxy cream control produce a higherskin permeation relative to other cream and gel formulations. It was notanticipated that the oil phase components of the control formulationwould result in an increase in the cumulative amount of oxymetazolinerelative to the compositions in Table 1b because oxymetazoline ishydrophilic.

Example 3: Clinical Efficacy and Safety of Oxymetazoline HCl CreamFormulations

Clinical Study Objectives

To evaluate the safety and efficacy of oxymetazoline HCl cream 0.5%,1.0%, and 1.5%, once-daily and twice-daily topical application comparedto vehicle for 28 consecutive days for the treatment of patients withmoderate to severe facial erythema associated with rosacea.

Methodology

Structure: Multicenter, randomized, double-blind, parallel-group,vehicle-controlled study

Duration: Approximately 86 days, up to a 30-day screening period, 28-daytreatment period, and 28-day follow-up period

Study Treatment Groups: Oxymetazoline HCl cream 0.5%, 1.0%, and 1.5%

Control: Vehicle cream

Dosage/Dose Regimen:

Group 1 Oxymetazoline 0.5% once-daily (hereafter referred to as Oxy 0.5%QD) Group 2 Oxymetazoline 1.0% once-daily (hereafter referred to as Oxy1.0% QD) Group 3 Oxymetazoline 1.5% once-daily (hereafter referred to asOxy 1.5% QD) Group 4 Vehicle once-daily (hereafter referred to asvehicle QD) Group 5 Oxymetazoline 0.5% twice-daily (hereafter referredto as Oxy 0.5% BID) Group 6 Oxymetazoline 1.0% twice-daily (hereafterreferred to as Oxy 1.0% BID) Group 7 Oxymetazoline 1.5% twice-daily(hereafter referred to as Oxy 1.5% BID) Group 8 Vehicle twice-daily(hereafter referred to as vehicle BID)

Duration of dosing for all 8 groups was 28 consecutive days. Patientsassigned to the once-daily dosing groups were instructed to apply studymedication in the morning each day. Patients assigned to the twice-dailydosing groups were instructed to apply study medication in the morningand a second dose approximately 6 to 10 hours after the morning dose. Ondays 1, 2, 14, and 28, all patients were instructed to apply the studymedication at the clinic. Patients in the twice-daily dosing groups wereinstructed to apply the second dose 6 hours after the morning dose atthe clinic.

Randomization/Stratification: At each investigational site, eligiblepatients were randomized to 1 of 8 treatment groups in a 1:1:1:1:1:1:1:1ratio to receive either once or twice daily application of oxymetazolineHCl cream 0.5%, 1.0%, or 1.5% or vehicle.

Visit Schedule: 8 scheduled study visits: screening (days −30 to −2),treatment period (days 1, 2, 14, and 28), follow-up (days 29 and 35),and exit (day 56)

Number of Patients (Planned and Enrolled)

Approximately 360 patients were planned to be enrolled. A total of 357patients were enrolled, of which 356 patients were randomized: 45, 44,44, 44, 45, 45, 45, and 44 patients were randomized to the Oxy 0.5% QD,Oxy 1.0% QD, Oxy 1.5% QD, vehicle QD, Oxy 0.5% BID, Oxy 1.0% BID, Oxy1.5% BID, and vehicle BID treatment groups, respectively.

Diagnosis and Main Criteria for Eligibility

Condition/Disease: Moderate to severe facial erythema associated withrosacea

Key Inclusion Criteria: Male or female patients 18 years of age or olderwith moderate to severe facial erythema associated with rosacea definedas a grade of ≥3 on the Allergan Clinician Erythema Assessment (CEA)scale with photonumeric guide as assessed by the investigator and either“more redness than I prefer” or “completely unacceptable redness” on theSubject Self-Assessment (SSA) of erythema scale as assessed by thepatient, and stable facial erythema associated with rosacea with minimalvariation from day to day and within each day, in the opinion of thepatient.

Key Exclusion Criteria: Any uncontrolled systemic disease or any of thefollowing conditions: clinically unstable hypertension, orthostatichypotension, clinically unstable cerebral insufficiency, coronaryinsufficiency, cardiac arrhythmia (ie, tachyarrhythmias, advancedventricular arrhythmias), ischemic heart disease, benign prostatehypertrophy, or Raynaud's syndrome. Greater than 3 inflammatory lesionson the face, facial acne that may have interfered with study assessmentsas determined by the investigator, clinical signs of actinic damage (eg,actinic lentigines, mottled hyperpigmentation or hypopigmentation,yellowish discoloration, excessive telangiectasia) on the face that mayhave interfered with study evaluations in the opinion of theinvestigator, narrow angle glaucoma, current use of monoamine oxidase(MAO) inhibitors.

Test Product, Dose and Mode of Administration, Batch Number:

Oxymetazoline HCl cream 0.5%, 1.0%, or 1.5% administered topically tothe face by the patient once or twice daily, based on the randomizationassignment; formulation numbers 11007X (0.5%), 11008X (1.0%), 11009X(1.5%); batch numbers EHC-C (0.5%), EHD-C (1.0%), EHE-C (1.5%).

Reference Therapy, Dose and Mode of Administration, Batch Number:

Oxymetazoline HCl cream vehicle administered topically to the face bythe patient once or twice daily, based on the randomization assignment;formulation number 11006X; batch number EHB-C.

Duration of Treatment:

The total duration of study participation for each patient wasapproximately 86 days and each patient received treatment forapproximately 28 consecutive days.

Efficacy, Health Outcomes, Drug Concentration, Safety, and OtherMeasurements

Efficacy:

Efficacy measures were:

-   -   investigator's assessment of the severity of facial erythema        using the CEA scale with photonumeric guide    -   patient's assessment of the severity of facial erythema using        the SSA of erythema scale

An additional efficacy measure was included in this study as anexploratory measure to assess the patient's perception of facialerythema (using different response options/categories of erythema thanthe SSA) for potential use in future studies.

-   -   the patient's assessment of the severity of facial erythema as        measured by the Subject Self-Assessment for Rosacea Facial        Redness (referred to as SSA-2), which included a photoguide.

The SSA-2 is similar to the SSA in that it is a 5-point patientassessment of facial redness from a score of 0 (clear) to 4 (severe);however, patients use a photoguide (similar to the CEA photonumericguide) to complete their assessments.

Health Outcomes:

The following patient-reported outcome (PRO) measures were included inthis study as exploratory measures to assess treatment responsivenessand determine an appropriate responder definition for use in futurestudies:

-   -   the patient's assessment of symptoms associated with erythema as        measured by the Symptom Assessment for Rosacea Facial Redness        (Symptoms Assessment)    -   the patient's assessment of functional impacts (eg, emotional,        social) associated with erythema as measured by the Impact        Assessment for Rosacea Facial Redness (Impact Assessment)    -   the patient's assessment of satisfaction with treatment as        measured by the Satisfaction Assessment for Rosacea Facial        Redness (Satisfaction Assessment: baseline and follow-up        versions)        Drug Concentration:

Blood samples were drawn on days 1 and 28 at predose, 2, 4, 6, 8, 10,and 12 hours after the morning dose throughout the study. Additionaltrough samples were collected on days 2, 14, and 29. The finalpharmacokinetic sample was collected on day 35 after all assessmentswere completed. Plasma was analyzed for oxymetazoline concentrationsusing a validated liquid chromatography-tandem mass spectrometry methodwith a lower limit of quantification of 10 pg/mL.

Safety:

Adverse events, facial dermal tolerability assessment, 12-leadelectrocardiograms (ECGs), laboratory tests (fasting biochemistry andhematology, urinalysis), urine pregnancy tests for women of childbearingpotential, physical examinations, vital sign measurements (bloodpressure, pulse rate, respiratory rate, and oral body temperature).

Other Measures:

Other measures included Clinician Telangiectasia Assessment (CTA),lesion count, Aesthetic Questionnaire, and standardizedphotography/digital image analysis (DIA).

Statistical and Data Analysis Methods

Analysis Populations:

The following 3 populations were analyzed. The modified intent-to-treat(mITT) population consisted of all randomized patients who applied studymedication during the study, had both CEA and SSA measurements atbaseline (ie, predose on day 1), and at least 1 postbaseline measurementfor both CEA and SSA. The per-protocol (PP) population consisted ofrandomized patients with no major protocol violation during the study.The PP population was determined prior to database lock. The safetypopulation consisted of patients who applied at least 1 dose of studymedication in the study. Efficacy analyses were performed on the mITTpopulation as the primary population. Primary efficacy analyses werealso performed on the PP population. Safety analyses were based on thesafety population.

Primary Efficacy Analysis:

The primary efficacy variable was defined as patients with at least a2-grade decrease (improvement) on both CEA and SSA from baseline(predose on day 1) over a 12-hour period measured at hours 2, 4, 6, 8,10, and 12 on day 28. A generalized linear model with a logit linkfunction and exchangeable covariance structure using generalizedestimation equations (GEE) was performed to analyze the primary variableat hours 2, 4, 6, 8, 10, and 12 on day 28 to compare treatmentdifference (ie, Oxy 0.5% QD versus vehicle QD, Oxy 1.0% QD versusvehicle QD, and Oxy 1.5% QD versus vehicle QD, separately). The modelincluded fixed effects of treatment group and timepoint. Similaranalyses were performed to compare each active twice-daily treatmentgroup to vehicle twice-daily.

Secondary Efficacy Analysis:

The secondary efficacy variables were defined as follows: the proportionof patients with at least a 2-grade decrease (improvement) on both CEAand SSA from baseline at hour 0.5 postdose on day 28; and the proportionof patients with at least a 2-grade decrease (improvement) on both CEAand SSA from baseline at 1 hour postdose on day 28. A frequencydistribution of patients with at least a 2-grade decrease (improvement)on both CEA and SSA by timepoint (hours 0.5 and 1) on day 28 andtreatment group was tabulated. A 2-sided 90% confidence interval (CI)for the treatment difference (ie, each active treatment minus vehicle)by timepoint was provided using a normal approximation method. APearson's chi-square test was used to test the treatment difference. If25% or more of the cells had expected counts less than 5, a Fisher'sexact test was used.

The same statistical method used in the primary efficacy analysis wasused to analyze the primary variable between 2 active treatment groups(eg, Oxy 1.5% QD versus Oxy 0.5% QD). In addition, a frequencydistribution of patients with at least a 2-grade decrease (ie, treatmentresponder) on both CEA and SSA by timepoint (hours 2, 4, 6, 8, 10, and12) on day 28 and treatment group was tabulated. A 2-sided 90% CI forthe treatment difference (ie, Oxy 0.5% QD minus vehicle QD, Oxy 1.0% QDminus vehicle QD, and Oxy 1.5% QD minus vehicle QD, separately) bytimepoint was provided using a normal approximation method. The sameanalyses were performed for twice-daily dosing and for the differencebetween 2 active treatment groups (eg, Oxy 0.5% BID and Oxy 1.0% QD).

Health Outcomes Analysis:

The health outcomes analyses were defined as the proportion of patientswith at least a 1-grade improvement on each question of the 3 PROmeasures from baseline on day 28.

Pharmacokinetic Analysis:

Noncompartmental analysis was performed to determine the maximumobserved plasma concentration (C_(max)), corresponding time to reachmaximum observed plasma concentration (T_(max)), area under the plasmaconcentration-time curve from time 0 to time t (AUC_(0-t)), accumulationratio (R₀), and effective half-life (T_(eff)) of oxymetazoline inplasma. These parameters were calculated, whenever possible.

Safety Analysis:

For pretreatment adverse events (PTAEs), number and percent of patientsreporting the PTAEs at least once were tabulated by descending order ofincidence rate, by primary system organ class (SOC) and by preferredterm (PT), and primary SOC, PT, and severity. Treatment-emergent adverseevents (TEAEs) regardless of causality were analyzed in the same manner.All analyses were by treatment group. Each active once-daily treatmentgroup was compared to vehicle once-daily using a Pearson's chi-squaretest or a Fisher's exact test if 25% or more of cells had expectedcounts less than 5. The same analyses were performed for twice-dailydosing groups. Treatment-related TEAEs were analyzed using the samestatistical methods as the TEAEs. Data from facial dermal tolerabilityassessments were summarized using frequency distributions and shifttables by treatment group. All other safety data were summarized bydescriptive statistics or frequency distribution.

Summary of Results

Patient Disposition and Demographics:

A total of 357 patients were enrolled into the study, of which 356patients were randomized. A majority of patients (95.2% [339/356])completed the study. In the twice-daily treatment groups, 6.7% (9/135)of the Oxy patients and 4.5% (2/44) of the vehicle patients discontinuedthe study. In the once-daily treatment groups, 3.0% (4/133) of the Oxypatients and 4.5% (2/44) of the vehicle patients discontinued the study.The primary reason for discontinuation from the study was adverse eventsin 2.8% (10/356) of all patients.

The demographic variables were similar across all treatment groups. Themean age of the patients was 50.0 years (range 19 to 79 years). Thelargest proportion of patients (60.4%) was aged between 45 and 64 yearsof age, with 29.5% being <45 years of age, and 10.1% being ≥65 years ofage. There were more females than males (80.1% versus 19.9%), and themajority of the population was Caucasian (91.3%).

Efficacy:

-   -   A statistically significant reduction in facial erythema as        measured by the composite assessment, i.e., the proportions of        patients with at least a 2-grade decrease (improvement) from        baseline over a 12-hour period for both the CEA and SSA on day        28, was demonstrated with the 1.5% and 1.0% doses of        oxymetazoline cream following twice-daily dosing (p=0.006 and        p=0.021, respectively), and with all 3 doses of oxymetazoline        cream (1.5%, 1.0%, and 0.5%) following once-daily dosing        (p=0.012, p=0.006, and p=0.049, respectively).    -   The proportions of responders in the twice-daily treatment        groups at hour 4 (peak timepoint) on day 28 were 22.2%, 20.0%        and 11.1% with Oxy 1.5%, 1.0/o, and 0.5%, respectively, compared        to 6.8% with vehicle. The proportions of responders in the        twice-daily treatment groups were maintained at hour 12 on day        28, with 15.6%, 11.1% and 13.3% in the Oxy 1.5/0%, 1.0%, and        0.5% groups, respectively, compared to only 4.5% in the vehicle        group.    -   The proportions of responders in the once-daily treatment groups        at hour 4 (peak timepoint) on day 28 were 27.3%, 31.8% and 17.8%        with Oxy 1.5%, 1.0%, and 0.5%, respectively, compared to 4.5%        with vehicle. The proportions of responders in the once-daily        treatment groups were maintained at hour 12 on day 28, with        13.6%, 13.6%, and 13.3% in the Oxy 1.5%, 1.0%, and 0.5% groups,        respectively, compared to only 2.3% in the vehicle group.    -   A statistically significant difference based on the composite        2-grade improvement was observed as early as 2 hours after the        first application on day 1 for a majority of the Oxy treatment        groups compared with vehicle.    -   The pair-wise comparison showed no statistically significant        differences in response rates over a 12-hour time period on day        28 between any of the Oxy twice-daily or once-daily treatment        groups, demonstrating that twice-daily dosing did not provide        any significant improvement over once-daily dosing for any of        the Oxy treatment groups. A numerically higher response rate was        observed for Oxy 1.0% QD versus Oxy 0.5% QD at most timepoints.        When comparing the Oxy 1.5% QD and the 1.0% QD doses, the        response rates were similar.    -   For the secondary efficacy variables (defined as the proportions        of patients with at least a 2-grade improvement on both the CEA        and SSA from baseline at hour 0.5 and hour 1.0 after application        of the first dose on day 28), only the Oxy 1.5% QD treatment        group showed statistically significant differences compared with        vehicle at hour 1.0.    -   The response rates on day 28 were higher compared with response        rates on day 1 for all Oxy treatment groups, demonstrating that        no tachyphylaxis was observed during the study.    -   A statistically significant reduction in rosacea facial redness,        as demonstrated by the proportions of patients with at least a        2-grade decrease (improvement) from baseline over a 12-hour        period for both the CEA and SSA-2, was observed with Oxy 1.5%        and 1.0% given twice-daily and once-daily compared with vehicle        on day 28, with responses observed as early as day 1.    -   Correlation analyses demonstrated that there was a high        correlation between the SSA and SSA-2 with a Spearman        correlation coefficient of 0.85 (90% CI [0.842, 0.851]).    -   There were no statistically significant between-group        differences in the proportions of responders at any timepoint        during the 4-week posttreatment period. During this follow-up        phase, During this follow-up phase, no patients had rebound or        worsening of erythema, as defined by a 1-grade worsening from        baseline on both of the CEA and SSA scales, as well as both of        the CEA and SSA-2 scales.    -   Subgroup analyses of the primary efficacy variable demonstrated        that treatment with oxymetazoline was efficacious in the        reduction of erythema regardless of sex, age, CEA score at        baseline, or SSA score at baseline.        Health Outcomes:

A summary of the proportion of patients with at least a 1-gradeimprovement on each question of the PRO measures from baseline on day 28is provided below. Note that all PRO measures were administered atpredose (prior to treatment) for validation purposes (for a separatestudy), which may have resulted in lower scores.

-   -   On day 28, the proportions of patients with at least a 1-grade        improvement on each question of the Symptom Assessment PRO        ranged from 35.6% to 68.9% for the active treatment groups        (once-daily and twice-daily) compared to 31.8% to 72.7% for the        vehicle groups, suggesting appropriate responsiveness to active        treatment with oxymetazoline.    -   The proportions of patients with at least a 1-grade improvement        on each question of the Impact Assessment PRO were similar for        all treatment arms on day 28. The proportions ranged from 21.4%        to 77.8% for the active treatment groups compared to 23.3% to        77.3% for the vehicle groups.    -   On day 28, the proportions of patients with at least a 1-grade        improvement on each question of the Satisfaction Assessment were        up to 43.2% for the active treatment groups and up to 45.2% for        the vehicle groups.        Pharmacokinetics:    -   Pharmacokinetic parameters, where applicable, were calculated        for each patient following dermal administration of        oxymetazoline cream. The maximum concentrations in the        once-daily and twice-daily dose groups were observed between 6        to 12 hours (median T_(max)) and 4 to 6 hours (median T_(max))        postdose, respectively. Following once-daily dosing, the mean        C_(max) in the 1.5% dose group on day 28 was 98.0 pg/mL which        was similar to the 115 pg/mL mean C_(max) observed in the Oxy        1.5% BID treatment group on day 28. The highest mean AUC₀₋₂₄        following administration of 1.5% once-daily or twice-daily was        1680 and 2660 pg·hr/mL, respectively.    -   With an increase in dosing frequency (twice-daily), there did        not appear to be a dose proportional increase in systemic        exposure when compared to once-daily dosing. Systemic exposure        appeared to increase nearly dose proportionally. Following 28        days of dosing, a mean accumulation ratio of approximately 2 was        observed across all once-daily treatment groups. Increased        accumulation was observed in the twice-daily treatment groups,        with a mean accumulation ratio between 4.86 to 6.48 when        comparing AUC after the first dose on days 1 and 28.    -   Data indicates that steady state may have been reached by the        second dose for the once-daily groups and after the third dose        for the twice-daily groups. An effective half-life of 18 to 28        hours was observed following repeated dermal administration of        oxymetazoline cream.        Digital Image Analysis:    -   Among the 6 measures evaluated from the DIA (ie, Fractional        Area, Erythema Severity, Erythema Redness, Erythema Contrast,        Intensity of Erythema, and Erythema Visibility), Fractional Area        had the best correlation with the CEA scale, with a Spearman        correlation coefficient of 0.47 (95% CI [0.436, 0.498]). In        general, there was a good differentiation on the improvement        from baseline in Fractional Area between the Oxy once-daily        groups and the vehicle once-daily group.        Safety:    -   All 3 doses of oxymetazoline (1.5%, 1.0%, and 0.5%) were        well-tolerated after once-daily or twice-daily application for        up to 28 consecutive days, with TEAEs reported in 33.1%        (118/356) of all patients and treatment-related adverse events        reported in 9.8% (35/356) of patients.    -   The overall incidences of TEAEs and treatment-related TEAEs were        similar across the 3 Oxy twice-daily treatment groups, but        slightly higher in the Oxy 1.5% QD group than the Oxy 1.0% and        0.5% QD groups. Most TEAEs were considered to be of mild or        moderate severity.    -   The most frequently reported TEAEs (in ≥2% of all patients) were        headache, application site dermatitis, contact dermatitis, upper        respiratory tract infection, application site papules,        application site erythema, and application site acne.    -   Treatment-related TEAEs were reported in 28        oxymetazoline-treated patients and 5 vehicle-treated patients.        The most frequently reported treatment-related TEAEs (in >1% of        all patients) were application site events, including        dermatitis, papules, pain (ie, stinging, burning), erythema,        pruritus, and acne. A majority of the events were mild or        moderate in severity and resolved without sequelae. Most of        these application site events (except 4 cases of acne and        papules) were resolved in the 4-week posttreatment follow-up        period.    -   The most frequently reported non-application site TEAE was        headache, which occurred similarly in oxymetazoline-treated        patients and vehicle-treated patients (4.9% and 4.5%,        respectively).    -   A total of 2.8% (10/356) of patients discontinued the study due        to TEAEs (8 oxymetazoline-treated patients and 2 vehicle-treated        patients), the majority of which were due to application site        adverse events, including application site dermatitis,        application site acne, application site erythema, application        site pruritus, application site irritation, and application site        pain.    -   There were no deaths reported during the study. There were 5        serious adverse events reported in 3 patients, none of which        were considered to be related to study treatment.    -   Subgroup analyses demonstrated that the incidence of TEAEs was        similar across the age and sex subgroups.    -   The proportions of patients with worsening in severity of facial        tolerability were similar between oxymetazoline-treated and        vehicle-treated patients following twice-daily or once-daily        dosing on days 1, 14, and 28, demonstrating that all Oxy        treatment groups had an acceptable local tolerability profile.    -   There were no clinically relevant changes from baseline or        differences between treatment groups with respect to laboratory        values, vital signs, and physical examination findings.    -   There was no increase in mean lesion counts or in the        proportions of patients with moderate or severe telangiectasia        in any of the treatment groups during the study or posttreatment        period.    -   There were no clinically relevant ECG findings observed during        the study.        Conclusion(s)

This multicenter, randomized, double-blind, vehicle-controlled,parallel-group study demonstrated that oxymetazoline hydrochloride creamat concentrations of 1.5%, 1.0%, and 0.5% given once daily significantlyreduced the facial erythema associated with rosacea, as assessed by theinvestigator using the CEA and by the patient using the SSA. Astatistically significant reduction in facial erythema was alsodemonstrated with the 1.5% and 1.0% doses of oxymetazoline creamfollowing twice-daily dosing (with the second dose administered 6 hoursafter the first dose); however, no additional treatment benefit wasobserved with twice-daily dosing over once-daily dosing. Allconcentrations of oxymetazoline were well tolerated when administeredonce or twice daily, with the majority of adverse events limited tolocalized dermatological effects.

List of Abbreviations and Definition of Terms Abbreviation/ TermDefinition ACL anterior cruciate ligament AQ Aesthetic QuestionnaireAUC_(0-t) area under the plasma concentration-time curve from time 0 totime t BID twice daily BLQ below the lower limit of quantitation CEAClinician Erythema Assessment CI confidence interval C_(max) maximumobserved plasma concentration CTA Clinician Telangiectasia AssessmentDIA digital image analysis DMP Data Management Plan ECGelectrocardiogram eCRF electronic case report form EDC electronic datacapture ERT eResearch Technology FDA Food and Drug Administration GCP(s)Good Clinical Practice(s) GEE generalized estimation equations HClhydrochloride HIPAA Health Insurance Portability and Accountability ActICF informed consent form ICH International Conference on HarmonisationIPL intense pulsed light IRB Institutional Review Board IVRS interactivevoice response system IWRS interactive web response system LC-MS/MSliquid chromatography-tandem mass spectrometry LLOQ lower limit ofquantitation MAO monoamine oxidase MedDRA Medical Dictionary forRegulatory Activities min minute mITT modified intent-to-treat NA or N/Anot applicable or not available OTC over-the-counter Oxy oxymetazolinehydrochloride PDF portable document format PDT photodynamic therapy PEGpolyethylene glycol PP per protocol PRO patient-reported outcome PTpreferred term PTAE pretreatment adverse event R₀ accumulation ratio QDonce daily QTcB QT interval corrected using the Bazett's correction QTcFQT interval corrected using the Fridericia's correction SOC system organclass SOP(s) standard operating procedure(s) SSA SubjectSelf-Assessment; Subject Self- Assessment of Erythema Scale SSA-2Subject Self-Assessment for Rosacea Facial Redness (with photo guide)T_(1/2) terminal half-life T_(eff) effective half-life TEAEtreatment-emergent adverse event T_(max) time corresponding to maximumobserved plasma concentration US United States1. Introduction

Oxymetazoline hydrochloride (HCl) is a potent and highly specificala-adrenergic receptor agonist and an effective vasoconstrictor. It iscurrently approved by the United States (US) Food and DrugAdministration (FDA) as an over-the-counter (OTC) eye drop product forthe indications of conjunctivitis and ocular irritation, and as an OTCnasal spray for nasal congestion (Oxymetazoline: DRUGDEX®). Each routeof administration uses a different formulation and concentration ofoxymetazoline (eye drops up to 0.025% and nasal sprays up to 0.05%). Inthe current study, oxymetazoline HCl was formulated as a cream (referredto hereafter as oxymetazoline cream) for topical facial dermalapplication and was being evaluated for the treatment of erythemaassociated with rosacea.

Rosacea is a common, chronic dermatological condition of uncertainetiology that is characterized by a myriad of clinical manifestations,including persistent erythema (which may be accompanied by facialstinging and burning), facial edema, superficial telangiectasias,recurrent papules and pustules, facial phymas (most commonlyrhinophyma), and ocular manifestations (Rebora, 2002). It is estimatedto affect more than 16 million Americans (National Rosacea Society,2012). Rosacea is common, especially in fair-skinned individuals ofCeltic or northern European origin (Jansen and Plewig, 1997). Its onsetis typically between the ages of 30 and 50, and women are affected 2 to3 times more often than men (Jansen and Plewig, 1997; Norwood andNorwood, 2007). Of all the clinical manifestations of rosacea, facialflushing and persistent erythema are among the most common and are oftenassociated with psychological distress (Breneman et al. 2004; Drummondand Su, 2012; Su and Drummond, 2012). Although the precise etiology andpathogenesis of erythematosus rosacea remain uncertain, it is theorizedthat abnormal flushing and persistent erythema result from a progressivedysregulation in the cutaneous vasomotor response (ie, persistentlydilated facial blood vessels) (Crawford et al. 2004; Parodi et al.1980). Evaluation of neurovascular and neuroimmune changes of rosaceausing quantitative real-time polymerase chain reaction andimmunohistochemistry supports the significant presence of vasodilatationof blood vessels and lymphatics in rosacea, demonstrates theupregulation of genes involved in vasodilatation, and supports theobservation that blood vessels in rosacea retain their ability torespond to vasoactive stimuli (Del Rosso, 2012).

While rosacea is not curable, it is a treatable condition; treatmentgoals include alleviation of signs and symptoms, improvement ofappearance, and delay or prevention of advancement of the condition.Effective treatments have been developed to treat papulopustular rosaceausing topical anti-infective agents such as sulfonamides, metronidazole,azelaic acid, and tetracyclines (Elewski et al, 2011).

Conspicuous facial redness may have a deep impact on a patient'sself-esteem and quality of life. Surveys of rosacea patients conductedby the National Rosacea Society indicate that more than 76% had loweredself-esteem and self-confidence; of rosacea patients with severesymptoms, 88% said the condition had adversely affected theirprofessional interactions (National Rosacea Society, 2012).

Five clinical studies of topical, dermal oxymetazoline have beenconducted for the treatment of facial erythema associated with rosaceaby Allergan and Vicept Therapeutics, Inc. All clinical studies have beenconducted with the same cream formulation with varying concentrations ofoxymetazoline. Across these studies, 314 patients with rosacea have beenexposed to the cream formulation with concentrations of oxymetazolinevarying from 0.01% to 1.5%.

A phase 1, multicenter, randomized, double-blind, vehicle-controlled,parallel-group, split face study in patients with stable moderate tosevere erythema associated with rosacea (Study 199201-001) demonstratedthat topical facial administration of oxymetazoline cream 1.5%, 1.0%,and 0.5% twice-daily for 5 consecutive days were well tolerated. Therewere no serious adverse events and no patients discontinued the study.The majority of the treatment-emergent adverse events (TEAEs) reportedwere considered related to study treatment and were mild or moderate inseverity. The proportion of responders, defined as patients' facialsites (left or right) with at least a 2 grade improvement on both theClinician Erythema Assessment (CEA) and Subject Self-Assessment (SSA)scales, increased in a dose-dependent manner for the majority oftimepoints. The best response rates were observed with oxymetazoline1.0% and 1.5%. A peak in response rate was observed at 4 hours postdose.The proportion of responders at hour 4 on day 1 was 37.5% withoxymetazoline 1.5%, 34.4% with oxymetazoline 1.0%, and 18.8% withoxymetazoline 0.5%, compared to 0.0% with vehicle. On day 1, theproportion of responders was statistically significantly superior tovehicle with oxymetazoline 1.5% at 2, 4, 6, and 10 hours postdose; withoxymetazoline 1.0% at 1, 2, 4, and 6 hours postdose; and withoxymetazoline 0.5% at 2, 4, and 6 hours postdose. Continued efficacy wasmaintained throughout the study; however, the results on day 1 were morepronounced than those on day 5.

Four randomized, double-blind, vehicle-controlled studies were conductedby Vicept in which patients with stable, moderate to severe erythemaassociated with rosacea received a single or once-daily facialapplication of oxymetazoline cream at concentrations of 0.01% to 0.5%.These studies included 254 patients who were treated with oxymetazolinecream. A bioavailability study demonstrated no measurable systemicexposure of oxymetazoline following application of 0.15% cream. A secondbioavailability study found the mean maximum concentration (C_(max)) andthe area under the plasma concentration-time curve (AUC) following anapplication of 0.5% cream to be approximately 7- and 6-fold lower,respectively, than those following administration of Afrin® nasal spray0.05%. Two vehicle-controlled dose-ranging studies with concentrationsup to 0.5% cream showed evidence of dose-dependent efficacy as evaluatedusing the CEA and SSA. The only TEAEs considered to be treatment-relatedin patients treated with oxymetazoline cream were erythema, pruritus,and eye irritation. There were no serious adverse events ordiscontinuations due to adverse events. There were no notable changesduring these studies in clinical laboratory tests, vital signs, or (inthe studies in which they were evaluated) electrocardiograms (ECGs) orintraocular pressure.

Results from these 5 studies support topical dermal safety ofoxymetazoline cream up to 1.5% twice-daily. Additionally, 4 human dermalsafety studies of 0.5% oxymetazoline cream (a 21 day cumulativeirritation study, a repeat-insult patch test, a phototoxicity study, anda photo contact-allergy study) indicate acceptable dermal safety withthe product. Detailed results of these studies can be found in theoxymetazoline cream Investigator's Brochure.

The current trial was designed to further evaluate the safety andefficacy of oxymetazoline cream in the treatment of facial erythemaassociated with rosacea at concentrations of 0.5%, 1.0%, and 1.5%, withlonger exposure (28 consecutive days) and administered once-daily ortwice-daily.

2. Study Objectives

To evaluate the safety and efficacy of oxymetazoline cream 0.5%, 1.0%,and 1.5%, once-daily and twice-daily topical application compared tovehicle for 28 consecutive days for the treatment of patients withmoderate to severe facial erythema associated with rosacea.

3. Investigational Plan

3.1 Overall Study Design and Plan

This was a multicenter, randomized, double-blind, vehicle-controlled,parallel-group study to investigate the safety, efficacy, facial dermaltolerability, and pharmacokinetic profile of oxymetazoline cream 0.5%,1.0%, and 1.5% (also referred to as Oxy 0.5%, Oxy 1.0%, and Oxy 1.5%,respectively) compared to vehicle (once-daily or twice-daily) topicalapplication in patients with moderate to severe facial erythemaassociated with rosacea.

The total duration of study participation for each patient was up toapproximately 86 days from the screening visit to study exit. The 8study visits included: screening (days −30 to −2), randomization day 1,treatment period visits (days 2, 14, and 28), follow-up (days 29 and35), and exit (day 56). After the screening visit, each qualifiedpatient returned on day 1 for confirmation of eligibility. Eligiblepatients were randomized and study medication was dispensed. Allpatients were to apply study medication for 28 consecutive days.

At the day 1, day 14, and day 28 visits, patients remained at the clinicfor at least 12 hours. During these study visits, patients applied studymedication at the clinic. At the day 2 visit, patients applied studymedication (morning dose only) at the clinic. Eligible patients wererandomized to 1 of 8 treatment groups as shown in a 1:1:1:1:1:1:1:1ratio.

Group 1 Oxymetazoline 0.5% once-daily (hereafter referred to as Oxy 0.5%QD) Group 2 Oxymetazoline 1.0% once-daily (hereafter referred to as Oxy1.0% QD) Group 3 Oxymetazoline 1.5% once-daily (hereafter referred to asOxy 1.5% QD) Group 4 Vehicle once-daily (hereafter referred to asvehicle QD) Group 5 Oxymetazoline 0.5% twice-daily (hereafter referredto as Oxy 0.5% BID) Group 6 Oxymetazoline 1.0% twice-daily (hereafterreferred to as Oxy 1.0% BID) Group 7 Oxymetazoline 1.5% twice-daily(hereafter referred to as Oxy 1.5% BID) Group 8 Vehicle twice-daily(hereafter referred to as vehicle BID)

Each of the 4 different treatments (oxymetazoline 0.5%, 1.0%, 1.5%, orvehicle) was administered once or twice daily for a total of 8 treatmentgroups. Study site staff and patients knew the regimen (once or twicedaily) but did not know the treatment that the patient was receiving.Treatment started after randomization on day 1 at the clinic. The sitestaff dispensed the study medication to patients and instructed them onhow to properly apply the study medication to their face. All patientsapplied study medication starting on day 1 through the day 28 visit. Thepatients assigned to groups 1, 2, 3, or 4 were instructed to apply studymedication in the morning each day. Patients assigned to groups 5, 6, 7,or 8 were instructed to apply study medication in the morning each dayand a second dose approximately 6 to 10 hours later.

3.2 Discussion of Study Design

This study used a randomized and double-blind design to minimizeinvestigator and patient bias. A vehicle-controlled, parallel-groupdesign eliminates many confounding effects that are inherent in otherstudy designs (eg, uncontrolled). Data from clinical studies to dateindicate a dose-dependent response for the reduction of facial erythemaas reported by scoring on the CEA and SSA scales, a clinician andpatient scale, respectively. Although a clear drug effect can be seenafter a single dose of oxymetazoline, it is not known to what extentthis efficacy may change over 4 weeks of continuous dosing. The peakdrug effect was observed 4 hours posttreatment after a single treatmentwith concentrations up to 1.5% (Study 199201-001). With daily dosing,the peak efficacy as well as maintenance of effective reduction inerythema may change over a 4-week dosing period. This study was designedto assess these changes at oxymetazoline concentrations of 0.5%, 1.0%,and 1.5% administered for 28 consecutive days.

In addition to evaluating the effect of once-daily dosing over a 12-hourobservation period, twice-daily dosing was included to study the effectof a second dose during the 12-hour observation period, with the intentto maintain a high level of efficacy over a period of 12 hours.

3.3 Selection of Study Population

The study included patients with moderate to severe facial erythemaassociated with rosacea. For enrollment into the study, each patient hadto meet all of the following inclusion criteria and none of thefollowing exclusion criteria.

3.3.1 Inclusion Criteria

Patients must have met the following inclusion criteria to be enrolledin the study:

-   -   male or female, 18 years of age or older    -   moderate to severe facial erythema associated with rosacea,        defined as a grade of ≥3 on the Allergan CEA scale with        photonumeric guide as assessed by the investigator    -   moderate to severe facial erythema associated with rosacea,        defined as either “more redness than I prefer” or “completely        unacceptable redness” on the SSA of erythema scale as assessed        by the patient    -   stable erythema associated with rosacea, with minimal variation        from day to day and within each day, in the opinion of the        patient    -   written informed consent had been obtained prior to any        study-related procedures    -   written Authorization for Use and Release of Health and Research        Study Information    -   ability to follow study instructions and complete study        assessment tools without assistance, and was likely to complete        all required visits including staying at the investigational        site for 3 separate visits that were to last for at least 12        hours        3.3.2 Exclusion Criteria

Patients were excluded from the study if they met any of the followingexclusion criteria:

-   -   any uncontrolled systemic disease    -   any of the following conditions: clinically unstable        hypertension, orthostatic hypotension, clinically unstable        cerebral insufficiency, coronary insufficiency, cardiac        arrhythmia (ie, tachyarrhythmias, advanced ventricular        arrhythmias), ischemic heart disease, benign prostate        hypertrophy, or Raynaud's syndrome    -   history or current evidence of drug or alcohol abuse within 12        months prior to the screening visit    -   narrow angle glaucoma    -   known hypersensitivity or allergies to any component of the        study treatment    -   greater than 3 inflammatory lesions on the face    -   facial acne that may have interfered with study assessments, as        determined by the investigator    -   clinical signs of actinic damage (eg, actinic lentigines,        mottled hyperpigmentation or hypopigmentation, yellowish        discoloration, excessive telangiectasia) on the face that might        have interfered with the study evaluations, in the opinion of        the investigator    -   any of the following procedures or treatments occurring within        the specified period prior to baseline assessments of erythema:        -   a. 2 hours:            -   any topical products including, but not limited to,                lotions, creams, ointments, and cosmetics applied to the                face (facial cleansers were allowed)        -   b. 14 days:            -   products containing oxymetazoline (eg, eye drops, nasal                sprays), topical glucocorticosteroids applied to the                face, any prescription or OTC product for the treatment                of acne or rosacea, and ANY product to reduce redness to                the face        -   c. 28 days:            -   systemic antibiotics that were known to have an effect                on rosacea        -   d. 180 days:            -   isotretinoin        -   e. 6 months:            -   laser, light-source (eg, intense pulsed light [IPL],                photodynamic therapy [PDT]) or other energy-based                therapy to the face    -   excessive facial hair, or other facial characteristics that        could have made assessments of erythema difficult, as determined        by the investigator    -   current use of monoamine oxidase (MAO) inhibitors    -   current use of niacin ≥500 mg/day    -   females who were pregnant, nursing, or planning a pregnancy        during the study or who were of childbearing potential not using        a reliable method of contraception and/or not willing to        maintain a reliable method of contraception during their        participation in the study    -   current enrollment in an investigational drug or device study or        participation in such a study within 30 days of entry into this        study    -   patient had a condition or was in a situation that, in the        investigator's opinion, that may have put the patient at        significant risk, may have confounded the study results, or may        have significantly interfered with the patient's participation        in the study    -   patients with a facial photograph that appeared in the Allergan        photonumeric guide were not eligible for participation        3.3.3 Removal of Patients from Therapy or Assessment

Patients could have voluntarily withdrawn from the study at any time.Additionally, patients could have been discontinued from the study by aninvestigator for reasons such as adverse events, pregnancy, loss tofollow-up, protocol violations, personal reasons, or lack of efficacy asdetermined by the investigator. The study could have been stopped at thestudy site(s) at any time by the site investigator(s). Allergan couldhave stopped the study (study site[s]) with appropriate notification.

If a patient discontinued participation in the study early, everyattempt was made to complete all exit study procedures, as indicated inTable 3-2, and an exit form outlining the reason for withdrawal was tobe completed. Notification of early patient discontinuation from thestudy and the reason for discontinuation was made to Allergan and wasclearly documented on the appropriate eCRF.

3.4 Treatments

3.4.1 Treatments Administered

Approximately 0.5 grams of oxymetazoline cream 0.5%, 1.0%, 1.5%, orvehicle was to be applied topically to the face by the patient once ortwice daily, based on the randomization assignment, for 28 consecutivedays.

Patients were instructed to wash their hands before and after eachapplication of study medication. The patient was to apply approximatelya pea size amount of study medication on the finger-tip and then dab thecream onto the erythematosus area of the face, gently spreading thestudy medication to thinly cover the entire face (hairline to mandibularridge and from ear to ear), and taking care not to over apply studymedication. A pea size amount of the study medication representedapproximately 0.5 grams of the product. Patients were instructed toavoid applying the study medication to the eyes, eyelids, scalp, neck,ears, and any membrane of the inner nose, mouth, lips, or open wounds.

3.4.2 Identity of Investigational Product(s)

Each tube of oxymetazoline hydrochloride 0.5% (Allergan formulationnumber 11007X, batch number EHC-C), 1.0% (Allergan formulation number11008X, batch number EHD-C), and 1.5% (Allergan formulation number11009X, batch number EHE-C) cream contained oxymetazoline HCl,methylparaben, propylparaben, phenoxyethanol, sodium citrate dihydrate,citric acid anhydrous, disodium edetate, butylated hydroxytoluene,anhydrous lanolin, medium chain triglycerides, diisopropyl adipate,oleyl alcohol, polyethylene glycol (PEG)-300, PEG-6 (and) PEG-32 (and)glycol stearate, cetostearyl alcohol, ceteareth-6 (and) stearyl alcohol,ceteareth-25, and purified water.

Each tube of oxymetazoline cream vehicle (Allergan formulation number11006X, batch number EHB-C) cream contained propylparaben,phenoxyethanol, methylparaben, sodium citrate dihydrate, citric acidanhydrous, disodium edetate, butylated hydroxytoluene, anhydrouslanolin, medium chain triglycerides, diisopropyl adipate, oleyl alcohol,PEG-300, PEG-6 (and) PEG-32 (and) glycol stearate, cetostearyl alcohol,ceteareth-6 (and) stearyl alcohol, ceteareth-25, and purified water.

Formulation characteristics are provided in Table 3-1.

TABLE 3-1 Formulation Characteristics Formulation FormulationCharacteristics Oxy 0.5% Oxy 1.0% Oxy 1.5% Vehicle Strength 5 mg/g 10mg/g 15 mg/g 0.0 mg/g Dosage form Topical Cream Topical Cream TopicalCream Topical Cream Bulk product lot EHC-C EHD-C EHE-C EHB-C numberPotency (% of label 0.5 1.0 1.5 0.0 claim) Manufacturing site DPT, DPT,DPT, DPT, San Antonio, San Antonio, San Antonio, San Antonio, TX TX TXTX Manufacturing date 19 Sep. 20 Sep. 21 Sep. 18 Sep. 2012 2012 20122012 Batch size 32 kg 32 kg 27 kg 32 kg Expiration/retest date 31 Aug.31 Aug. 31 Aug. 31 Aug. 2013 2013 2013 2013 Oxy = oxymetazolinehydrochlordide; TX = Texas3.4.3 Method of Assigning Patients to Treatment Groups

Prior to initiation of study treatment, each patient who providedinformed consent was assigned a patient number that served as thepatient identification number on all study documents throughout thestudy.

At the time of randomization on day 1, eligible patients were randomizedvia an automated interactive voice response system/interactive webresponse system (IVRS/IWRS) that was used to manage the randomizationand treatment assignment based on a randomization scheme prepared byAllergan Biostatistics. At each investigational site, eligible patientswere randomized to 1 of 8 treatment groups in a 1:1:1:1:1:1:1:1 ratio toreceive a once-daily or twice-daily regimen of oxymetazoline 0.5%, 1.0%,1.5%, or vehicle.

Study medication tubes were labeled with medication kit numbers. At thetime of randomization the IVRS/IWRS provided the site with the specificmedication kit number(s) for each randomized patient, corresponding tothe treatment group assigned via central randomization. Sites dispensedstudy medication according to the IVRS/IWRS instructions. Sites receivedthe IVRS/IWRS confirmation notifications for each transaction. Allnotifications were to be maintained with the study source documents.

On day 14, sites called the IVRS or logged onto the IWRS to obtain a kitnumber to dispense additional study medication to patients randomized totwice-daily dosing groups.

3.4.4 Selection of Doses in the Study

The doses of 0.5%, 1.0% and 1.5% oxymetazoline were selected based ondata obtained from nonclinical studies in rats and minipigs inconjunction with data from 4 clinical dermal safety studies (a 21-daycumulative irritation study, a repeat-insult patch test, a phototoxicitystudy, and a photo contact-allergy study) and 5 clinical studies.

3.4.5 Selection and Timing of Dose for Each Patient

As described in Section 3.2, in addition to evaluating the effect ofonce-daily dosing over a 12-hour observation period, twice-daily dosingwas included to study the effect of a second dose during the 12-hourobservation period, with the intent to maintain a high level of efficacyover a period of 12 hours. Based on their randomization assignment,patients were instructed to apply study medication to their facestarting on day 1 through the day 28 visit. Patients assigned to group1, 2, 3, or 4 (once-daily dosing groups) were instructed to apply studymedication in the morning each day. Patients assigned to group 5, 6, 7,or 8 (twice-daily dosing groups) were instructed to apply studymedication in the morning and a second dose approximately 6 to 10 hourslater. On days 1, 2, 14, and 28, all patients were instructed to applythe study medication at the clinic. The morning dose was to be appliedafter predose study assessments and procedures were complete. Patientsin the twice-daily dosing groups were to apply the second (evening dose)6 hour after the morning dose. On day 2 only the morning dose was to beapplied at the clinic.

3.4.6 Blinding

This was a double-blinded clinical trial. Study medications wereprovided in identical tubes and cartons to maintain study masking. Theinvestigator, investigator staff, and patients were masked to the studymedication.

If necessary for the safety and proper treatment of the patients, theinvestigator was able to unmask the patient's treatment assignment toconduct appropriate follow-up care. Whenever possible, Allergan was tobe notified before unmasking the study medication. The date andsignature of the person breaking the code as well as the reason forbreaking the code and any associated adverse events were to be recordedin the patient's source documentation.

3.4.7 Prior and Concomitant Therapy

3.4.7.1 Permissible Medications/Treatments

Therapy considered necessary for the patient's welfare may have beengiven at the discretion of the investigator. If the permissibility of aspecific medication/treatment was in question, Allergan was to becontacted.

3.4.7.2 Prohibited Medications/Treatments

The decision to administer a prohibited medication/treatment was madewith the safety of the study participant as the primary consideration.When possible, Allergan was to be notified before the prohibitedmedication/treatment was administered.

Prohibited Medications/Treatments:

-   -   the application of any facial products (eg, makeup, lotions, or        ointments) was prohibited during all study visits from 2 hours        before the first assessment and until all assessments were        complete. Use of facial products was permitted on all other        dosing days; however, they must have been removed at least 20        minutes before drug application and patients must have waited at        least 20 minutes after drug application before applying.    -   products containing oxymetazoline (eg, Afrin®, Vicks Sinex®,        Visine L.R.®, Ocuclear®, Zoamet®, Mucinex® nasal spray, Sudafed        OM® nasal spray) except for study medication    -   any prescription or OTC product for the treatment of acne or        rosacea    -   any prescription or OTC product that caused vasoconstriction or        was primarily used to decrease facial redness    -   topical retinoids    -   any topical treatment that may have affected erythema or caused        skin irritation    -   new topical facial regimens    -   systemic antibiotics that were known to have an effect on        rosacea    -   topical glucocorticosteroids applied to the face    -   any new use of systemic or inhaled glucocorticosteroids    -   MAO inhibitors    -   isotretinoin    -   niacin ≥500 mg/day    -   niacin ≤500 mg/day if not at a stable dose or if it was known to        cause flushing    -   systemic alpha-1 adrenergic receptor antagonists (eg,        tamsulosin, terazosin, doxazosin, and alfuzosin)    -   medications that the patient knew may have increased erythema or        flushing    -   patients were also to refrain from changing the use of any        concomitant therapies after the screening visit until study        completion        Prohibited Treatments    -   laser    -   light-source (eg, IPL or PDT)    -   other energy-based therapy to the face        Prohibited Activities 24 Hours Before Study Visits:    -   consumption of any food or beverage that was known to increase        erythema for the patient    -   use of saunas, steam rooms, and hot tubs, or any other        activities that were known to increase erythema for the patient        3.4.7.3 Special Diet or Activities

Twenty-four hours before the study visits, patients were to avoid anyfoods, beverages, or activities that were known specifically to them toincrease their facial erythema. In addition, patients were instructed toavoid all prohibited medications, treatments, and activities, asdescribed in Section 3.4.7.2.

Patients were instructed to fast (only water was permitted) for at least10 hours prior to blood collections for laboratory safety tests atscreening, day 29, and (if applicable) early exit. If a patient was notfasting at the screening visit, he/she was asked to return to the clinicfor laboratory safety tests prior to the day 1 visit.

Patients were to remain at the investigational site for at least 12hours during days 1, 14, and 28; the study site provided meals andbeverages. Patients were to only consume the food and beverages providedby the study staff. The meals provided were not to contain items thatmay have increased the patients' facial erythema, such as certainspices, caffeine, nicotine, hot beverages, or alcohol. Patients couldhave consumed water on an ad libitum basis.

3.4.8 Treatment Compliance

The investigator was instructed to keep an accurate accounting of thenumber of investigational units received from Allergan, dispensed to thepatients, the number of units returned to the investigator by thepatient, and the number of units returned to Allergan during and at thecompletion of the study. A detailed inventory was to be completed forthe study medication. The study medication was to be dispensed only byan appropriately qualified person to patients in the study. Themedication was to be used in accordance with the protocol by patientswho were under the direct supervision of an investigator.

All patients were to apply study medication topically to their face for28 consecutive days. On days 1, 14, and 28, patients applied the studymedication at the clinic (1 dose for the once-daily patients and 2 dosesfor the twice-daily patients). On day 2, patients applied only themorning dose at the clinic. The study medication tubes were weighedpredose and postdose for the morning treatment application and postdoseafter the evening treatment application at each in-clinic treatmentvisit. The weights were recorded on source documentation.

3.5 Efficacy, Health Outcomes, Drug Concentration, Safety, and OtherMeasurements

The study included scheduled visits at screening (days −30 to −2),randomization day 1, treatment period visits (days 2, 14, and 28),follow-up (days 29 and 35), and exit (day 56). The schedule of visitsand the study variables evaluated at each visit are presented in Table3-2. Evaluations were to be performed by the same evaluator throughoutthe study whenever possible. If it was not possible to use the sameevaluator to follow the patient, then evaluations were to overlap for atleast 1 visit.

Efficacy Measurements

3.5.1.1 Primary Efficacy Measurements

Efficacy measures were:

-   -   investigator's assessment of the severity of facial erythema        using the CEA scale with photonumeric guide    -   patient's assessment of the severity of facial erythema using        the SSA scale

The CEA and SSA scales are shown below.

CEA Scale

Grade Description 0 Clear skin with no signs of erythema^(a) 1 Almostclear of erythema, slight redness 2 Mild erythema, definite redness 3Moderate erythema, marked redness 4 Severe erythema, fiery redness^(a)Normal healthy skin color as seen in individuals without rosacea

SSA Scale

Grade Description 0 Clear of unwanted redness 1 Nearly clear of unwantedredness 2 Somewhat more redness than I prefer 3 More redness than Iprefer 4 Completely unacceptable rednessPrimary Efficacy Variable:

The primary efficacy variable was derived from the efficacy measures:the investigator's assessment of the severity of facial erythema usingthe 5-point CEA scale with photonumeric guide and the patient'sassessment of the severity of facial erythema using the 5-point SSAscale.

The primary efficacy variable was defined as a treatment responder athours 2, 4, 6, 8, 10, and 12 on day 28. A responder was defined as atleast a 2-grade improvement from baseline on both CEA and SSA. Thebaseline value was the value collected on day 1 predose (baseline). Ifday 1 predose data were missing, screening visit data was used.

3.5.1.2 Secondary Efficacy Measurements

The secondary efficacy variables were defined as follows:

-   -   proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline at hour 0.5        postdose on day 28    -   proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline at hour 1        postdose on day 28        3.5.1.3 Other Efficacy Measurements

An additional efficacy measure was included in this study as anexploratory measure to assess the patient's perception of facialerythema (using different response options/categories of erythema thanthe SSA) for potential use in future studies.

-   -   the patient's assessment of the severity of facial erythema as        measured by the Subject Self-Assessment for Rosacea Facial        Redness (referred to as SSA-2), which included a photoguide

The SSA-2 is similar to the SSA in that it is a 5-point patientassessment of facial redness from a score of 0 (clear) to 4 (severe);however, patients use a photoguide (similar to the CEA photonumericguide) to complete their assessments.

3.5.2 Health Outcomes Measurements

The following patient-reported outcome (PRO) measures were included inthis study as exploratory measures to assess treatment responsivenessand determine an appropriate responder definition for use in futurestudies:

-   -   the patient's assessment of symptoms associated with erythema as        measured by the Symptom Assessment for Rosacea Facial Redness        (hereafter referred to as Symptom Assessment)    -   the patient's assessment of functional impacts (eg, emotional,        social) associated with erythema as measured by the Impact        Assessment for Rosacea Facial Redness (hereafter referred to as        Impact Assessment)    -   the patient's assessment of satisfaction with treatment as        measured by the Satisfaction Assessment for Rosacea Facial        Redness (baseline and follow-up versions) (hereafter referred to        as Satisfaction Assessment)

Response options for each question in the PROs were on 5-pointadjectival and/or Likert-type scales.

3.5.3 Drug Concentration Measurements

Blood samples were collected from all patients to determineoxymetazoline concentrations in plasma at the following timepoints:

-   -   Day 1: predose, 2, 4, 6 (before evening dose for twice-daily        groups), 8, 10, and 12 hours after morning dose    -   Day 2: predose (24 hours after day 1 morning dose)    -   Day 14: predose, 6 (before evening dose for twice-daily groups)        and 12 hours after morning dose    -   Day 28: predose, 2, 4, 6 (before evening dose for twice-daily        groups), 8, 10, and 12 hours after morning dose    -   Day 29: 24 hours after day 28 morning dose    -   Day 35: after all assessments were completed

At the selected timepoints, approximately 6 mL of blood was collectedinto prelabeled K₂EDTA lavender top blood collection tubes and gentlyinverted at least 10 times to ensure adequate mixing of blood andanticoagulant. The tubes were immediately placed in an ice water bathfor at least 5 minutes and then centrifuged (refrigerated at 4° C.) for10 minutes at approximately 2,000×g (˜2,500 rates per minute). A minimumof 1.0 mL of the harvested plasma was transferred into 2 prelabeledcryovials and stored at −20° C. or below until analyzed. The sampleswere analyzed using a validated high performance liquidchromatography-tandem mass spectrometry (LC-MS/MS) method with a lowerlimit of quantitation (LLOQ) of 10 pg/mL.

3.5.4 Other Measurements

3.5.4.1 Clinician Telangiectasia Assessment

The Clinician Telangiectasia Assessment (CTA) was the investigator'sassessment of the average overall severity of telangiectasia on theapplication sites of the patient's face. The CTA was performed by theinvestigator at specified timepoints at screening, days 1, 14, 28, 29,35, and 56/study exit (Table 3-2). The assessments were not to becompared with CTA assessments at any other timepoint. The investigatorwas not to refer to any other evaluation to assist with theseassessments.

The CTA was performed based on the following scale:

Description 0 Clear skin with no signs of telangiectasia 1 Almost clear,a few barely visible telangiectasia 2 Mild, a few visible telangiectasia3 Moderate, with the presence of clearly visible telangiectasia 4Severe, with the presence of many visible telangiectasia3.5.4.2 Lesion Count

Lesion count of the face was done by the investigator at screening,predose on days 1, 14, and 28, and days 35 and 56/study exit.

3.5.4.3 Aesthetic Questionnaire

The Aesthetic Questionnaire (AQ) was administered to patients on days 14and 28 and assessed patient's facial skin type, other medication used totreat rosacea, ease of application, smell, speed of drying,greasiness/stickiness, moisturizing effect, glossy/shiny appearance,residue, and any effect of treatment on routine application of makeup orsunscreen.

3.5.4.4 Standardized Photography

Canfield Scientific, Inc. (Fairfield, N.J.) provided instructions fortaking photographs and processing digital photographs. Each sitereceived instructions and training on taking photographs.

Facial photographs were to be taken for all patients. Photographs ofpatients in treatment groups 1, 2, 3, and 4 (once-daily dosing) taken atpredose and 6 and 12 hours postdose on days 1, 14, and 28, and day 35were used for exploratory digital image analysis (DIA) related toerythema. Three views (ie, right view, frontal view, and left view) ofphotographs were taken for patients at each timepoint.

3.5.5 Safety Measurements

Safety measurements included adverse events, facial dermal tolerabilityassessment, 12-lead ECG, fasting biochemistry and hematology,urinalysis, urine pregnancy tests for women of childbearing potential,physical examination, and vital sign measurements (blood pressure, pulserate, respiratory rates, and body temperature).

3.5.5.1 Adverse Events

An adverse event was defined as any untoward medical occurrence in apatient administered a pharmaceutical product and that did notnecessarily have a causal relationship with study treatment. An adverseevent could therefore be any unfavorable and unintended sign (includingan abnormal laboratory finding), symptom, or disease temporallyassociated with the use of a medicinal (investigational) product,whether or not related to the medicinal (investigational) product. Inaddition, during the screening period, adverse events were assessedregardless of the administration of a pharmaceutical product.

Adverse events were assessed and documented, as appropriate, throughoutthe study (ie, after informed consent had been obtained). At each visit,the investigator began by querying for adverse events by asking eachpatient a general, non-directed question such as “How have you beenfeeling since the last visit?” Directed questioning and examination werethen done as appropriate. All reported adverse events were documented onthe appropriate eCRF.

3.5.5.1.1 Serious Adverse Events

A serious adverse event was defined as any adverse event occurring atany dose that resulted in any of the following outcomes: death, alife-threatening adverse event, inpatient hospitalization orprolongation of existing hospitalization, a persistent or significantdisability/incapacity, or a congenital anomaly/birth defect. Importantmedical events that may not have resulted in death, beenlife-threatening, or required hospitalization could have been considereda serious adverse event when, based upon appropriate medical judgment,they may have jeopardize the patient and may have required medical orsurgical intervention to prevent one of the outcomes listed in thisdefinition.

Note: Allergan considers all cancer adverse events as serious adverseevents. In addition, Allergan considers any abortion (spontaneous orelective) as a serious adverse event.

3.5.5.1.2 Severity

A clinical determination was made of the intensity of an adverse event.The severity assessment for a clinical adverse event was completed usingthe following definitions as guidelines:

Mild Awareness of sign or symptom, but easily tolerated. ModerateDiscomfort enough to cause interference with usual activity. SevereIncapacitating with inability to work or do usual activity. Notapplicable In some cases, an adverse event may have been an ‘all ornothing’ finding that could not be graded.3.5.5.1.3 Relationship to Study Drug or Study Procedure

A determination was made of the relationship (if any) between an adverseevent and the study drug or study procedure, as applicable. A causalrelationship was present if a determination was made that there was areasonable possibility that the adverse event may have been caused bythe drug or study procedure.

3.5.5.1.4 Procedures for Reporting Adverse Events

Any adverse event was to be recorded on the appropriate eCRF.

All adverse events that were drug-related and unexpected (not listed astreatment-related in the current Investigator's Brochure) were to bereported to the governing IRB as required by the IRB, local regulations,and the governing health authorities. Any adverse event that was marked“ongoing” at the exit visit was to be followed-up as appropriate.

3.5.5.1.5 Procedures for Reporting a Serious Adverse Event

Any serious adverse event occurring during the study period (beginningwith informed consent) and for at least 28 days after the last dose ofstudy drug was to be immediately reported to an Allergan representativelisted on the Allergan personnel page and recorded on the seriousadverse event fax form. All patients with a serious adverse event wereto be followed up and the outcomes reported. The investigator wasrequired to supply Allergan and the IRB with any additional requestedinformation (eg, autopsy reports and terminal medical reports).

3.5.5.2 Facial Dermal Tolerability Assessment

Facial dermal tolerability assessments were evaluated by investigatorsand patients at specified timepoints on days 1, 2, 14, 28, 35, and56/study exit. Facial dermal tolerability assessment included theinvestigator's assessments (dryness and scaling of the treatment area)and the patient's assessments (stinging/burning and pruritus [itching]of skin in the application area) as described below:

Investigator's assessments: dryness and scaling of the treatment area

Dryness: skin roughness

None (0) No dryness Mild (1) Slight but definite roughness Moderate (2)Moderate roughness Severe (3) Marked roughness

Scaling: abnormal peeling of the stratum corneum

None (0) No dryness Mild (1) Barely perceptible peeling, noticeable onlyon light scratching or rubbing Moderate (2) Obvious but not profusepeeling Severe (3) Heavy scale production

Patient's assessments: stinging/burning and pruritus (itching) of skinin the application area

The investigator asked the patient if he/she was experiencingstinging/burning and/or pruritus (itching) based on the scale below.

Stinging/Burning: prickling pain sensation

None (0) No stinging/burning Mild (1) Slight warm, tingling/stingingsensation; not really bothersome Moderate (2) Definite warm,tingling/stinging sensation that is somewhat bothersome Severe (3) Hot,tingling/stinging sensation that has caused definite discomfort

Pruritus: itching in the application area

None (0) Normal, no itching in the application area Mild (1) Noticeablediscomfort causing intermittent awareness Moderate (2) Noticeablediscomfort causing continuous awareness Severe (3) Definite, continuousdiscomfort interfering with normal daily activities3.5.5.3 Physical Examination

The investigator examined the patient for any physical abnormalities atscreening and study exit for the following body systems: generalappearance, head, eyes, ears, nose, throat, heart/cardiovascular, lungs,abdomen, neurologic, extremities, back, musculoskeletal, lymphatic,skin, and other findings. The patient's height and weight were recordedat screening only.

3.5.5.4 Vital Signs

Vital signs including pulse rate, systolic and diastolic bloodpressures, respiratory rate, and temperature were recorded at screeningand days 1, 2, 14, 28, 35, and 56/study exit.

3.5.5.5 Clinical Laboratory Evaluations

Patients had samples of blood (fasting) and urine collected atscreening, day 29, and day 56/study exit visits, as specified by thecentral laboratory, and used for the following tests:

Hematology: complete blood count including hemoglobin, hematocrit, redblood cells, white blood cells, red blood cell morphology, meancorpuscular volume, mean corpuscular hemoglobin, mean corpuscularhemoglobin concentration, white blood cell differential (% andabsolute), neutrophils, lymphocytes, monocytes, basophils, eosinophilsand platelets

Chemistry: glucose, creatinine, blood urea nitrogen, total bilirubin,aspartate aminotransferase (serum glutamic oxaloacetic transaminase),alanine aminotransferase (serum glutamic pyruvic transaminase), alkalinephosphatase, uric acid, sodium, potassium, bicarbonate (carbon dioxidecontent), chloride, phosphorus, calcium, total protein, albumin, andlactate dehydrogenase

Urinalysis: specific gravity, pH, color, protein, glucose, bloodketones, bilirubin, and microscopic examination

3.5.5.6 12-Lead ECGs

12-lead ECGs were performed at screening, day 1/baseline, and day 28using standardized equipment and electrode placement. A qualified thirdparty vendor (eResearch Technology [ERT]) read the ECGs and reported thefindings as normal, abnormal, or unable to evaluate. For screening ECGs,prespecified significant abnormal findings were flagged as exclusionalerts, and generated an exclusion alert for the site and sponsor. Forall subsequent ECGs, ERT also reported the appearance of any new,prespecified significant abnormal findings and generated a protocolalert for the site and sponsor. The cardiologists were blinded topatient treatment assignments.

3.5.5.7 Urine Pregnancy Test

Urine pregnancy tests were performed on females of childbearingpotential at screening, prior to dosing at day 1/baseline, day 35, andat study exit (or early discontinuation visit). Further urinarypregnancy tests could be performed at any time during the study at thediscretion of the investigator. A negative result was required prior toreceiving study medication.

If a patient became pregnant during the study, the investigator wasrequired to notify Allergan immediately after the pregnancy wasconfirmed and the patient was exited from the study after appropriatesafety follow-up. The investigator was required to notify the patient'sphysician that the patient may have been treated with an investigationalmedication (oxymetazoline or vehicle), follow the progress of thepregnancy to term, and document the outcome of the pregnancy.

3.5.6 Appropriateness of Measurements

The primary efficacy measures in this study were assessed by using theCEA scale with photonumeric guide and the SSA scale.

The CEA was developed by Allergan and validated in a single-center study(Study 199201-003) with 104 patients representing all 5 CEA scalegrades. Seven physician raters rated all subjects on the severity oftheir erythema using the 5-point CEA scale with photonumeric guide. Theerythema assessment and ratings on day 1 were performed twice, at least2 hours apart. Based on the weighted Kappa statistic there was“substantial” agreement for all 7 of the raters. The overall weightedKappa statistic was 0.752, which was “substantial” agreement. Theoverall Kendall statistic was 0.908 which was deemed “almost perfect”agreement among raters. The data demonstrated that the CEA scale withphotonumeric guide is a reliable instrument for grading the degree offacial erythema associated with rosacea.

The SSA tool has been derived from a similar tool used in Galdermastudies called the Patient Self Assessment. Allergan has furtherdeveloped the SSA instrument in accordance with the FDA PRO Guidance totest its content validity. Modifications were made to the SSA based onadditional development and it was renamed Subject Self-Assessment forRosacea Facial Redness (referred to in this study as SSA-2). The SSA-2is a single item rating scale designed for subject assessment ofseverity of facial erythema in the present moment. The content validityof the SSA-2 (including the relevance of its content and ability ofpatients to understand and use the instrument) was supported in aqualitative study (AL6749A). In this same study, the content validity ofthe CEA photoguide was also evaluated for subject use with the SSA-2 andwas shown to be valid. Psychometric properties of both the SSA and SSA-2with photoguide will be assessed in the oxymetazoline clinicaldevelopment program.

The safety measurements in this study are standard measures in clinicalresearch and are recognized as reliable, accurate, and relevant for thistherapeutic area.

The pharmacokinetic parameters reported in this study are the acceptedstandard recognized globally by scientists and regulatory authorities.

3.5.7 Schedule of Assessments

The frequency and timing of study visits and measurements are outlinedin Table 3-2. Additional examinations were to be performed as necessaryto ensure the safety and well-being of patients during the study.

TABLE 3-2 Schedule of Visits and Procedures Visit Number Visit 1 Visit 2Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8 Visit Day 29 Day 1/Follow- Day 35 Day 56/ Screening Baseline Day 2 Day 14 Day 28 upFollow-up Exit Visit Window ±0 Day ±3 Days ±3 Days Day −30 ≥12 hrs in≥12 hrs in ≥12 hrs in Study Procedures to −2 clinic ±0 Day clinic clinic±0 Day ±3 Days ±3 Days Consent/Authorization X Demographics XInclusion/Exclusion Criteria X predose Facial Photographs^(a) X predose,predose, predose, X X 6 and 12 hrs 6 and 12 hrs 6 and 12 hrs SubjectSelf-Assessment (SSA) of X predose, 0.5, 1, predose predose, 0.5, 1,predose, 0.5, 1, X X X Erythema Scale^(a) 2, 4, 6, 8, 10, 2, 4, 6, 8,10, 2, 4, 6, 8, 10, and 12 hrs and 12 hrs and 12 hrs SubjectSelf-Assessment for Rosacea X predose, 0.5, 1, predose predose, 0.5, 1,predose, 0.5, 1, X X X Facial Redness (SSA-2)^(a) 2, 4, 6, 8, 10, 2, 4,6, 8, 10, 2, 4, 6, 8, 10, and 12 hrs and 12 hrs and 12 hrsPatient-reported Outcomes (PROs) predose predose predose X X AestheticQuestionnaire (AQ) X X Clinician Erythema Assessment X predose, 0.5, 1,predose predose, 0.5, 1, predose, 0.5, 1, X X X (CEA)^(a) 2, 4, 6, 8,10, 2, 4, 6, 8, 10, 2, 4, 6, 8, 10, and 12 hrs and 12 hrs and 12 hrsClinician Telangiectasia Assessment X predose, 4, 8, predose, 4, 8,predose, 4, 8, X X X (CTA)^(a) and 12 hrs and 12 hrs and 12 hrs LesionCount X predose predose predose X X Facial Dermal Tolerability predose,1, 2, predose predose, 1, 2, predose, 1, 2, 4, X X Assessment 4, 6, 8,10, and 4, 6, 8, 10, and 6, 8, 10, and (Patient and Investigator)^(a) 12hrs 12 hrs 12 hrs Medical History X predose Height and Weight X VitalSigns Measurements X predose and predose predose and predose and X X 12hrs 12 hrs 12 hrs Physical Examination X X Electrocardiogram (ECG)^(a) Xpredose, predose, 6 and 12 hrs 6 and 12 hrs Blood Sample for Fasting X XX^(b) Biochemistry, Hematology^(c); Urine Sample for UrinalysisPharmacokinetic Sample^(a,c) predose, 2, 4, predose predose, 6 andpredose, 2, 4, 6, 24 hrs X 6, 8, 10, and 12 hrs 8, 10, and 12 hrs after12 hrs day 28 morning dose Pregnancy Test (Urine) X predose X XRandomization X Dispense Study Medication QD and BID BID group groupsWeigh Study Medication Tube morning: morning: morning: morning: predoseand predose predose and predose and postdose and postdose postdoseevening: postdose evening: evening: postdose postdose postdose Dosing(days 1-28) X X X X Concomitant Medications and X X X X X X X XConcurrent Procedures Adverse Events X X X X X X X X BID = twice dailydosing (groups 5, 6, 7, and 8); QD = once daily dosing (groups 1, 2, 3,and 4) ^(a)For the twice-daily groups 5, 6, 7, and 8, all assessments atthe 6-hour timepoint were to be performed before the evening dose at 6hours. ^(b)Only required for patients who discontinued prior to the day29 visit ^(c)Blood draws were always to occur after the SSA, SSA-2, andCEA assessments had been completed at all timepoints.3.6 Data Quality Assurance3.6.1 Study Monitoring

Allergan monitored the sites regularly during the study to assureprotocol adherence, proper eCRF and source documentation completion andretention, accurate study drug accountability, and was in frequentcontact through verbal and written communication. The Allergan monitorhad access to all documents related to the study and the individualparticipants at any time these were requested. All essential documentswere submitted to Allergan and copies retained at the study sites.Portable document format (PDF) copies of the eCRFs were distributed toeach site for archival at the end of the study.

3.6.2 Investigator Meetings and Staff Training

Allergan sponsored an investigators training meeting to discuss theprotocol procedures and conduct training on study requirements. Trainingwas also conducted via a training portal. CEA training was conductedusing live patients with/without rosacea, and with varying severity oferythema. A study initiation visit by the Allergan monitor was performedat all sites prior to the start of the study to review the studyprotocol in detail and ensure the availability of appropriate studypersonnel and compliance with GCP regulations and procedures. Inaddition, for those investigators who were unable to attend theinvestigator meeting, along with the Allergan monitor, additionalAllergan clinical research personnel conducted onsite investigatortraining.

3.6.3 Clinical Data Management

Clinical Data Management personnel received, processed, and reviewed alldata following Allergan Standard Operating Procedures (SOPs).

Study data entered into the electronic data capture (EDC) tool (OracleInForm version 5.0) by the investigational site personnel wastransferred to Allergan Clinical Data Management through validated andsecured methods. Other data sources included Perceptive Informatics(used to assign subject, randomization, and medication kit numbers, andto manage medication), Covance Central Laboratory Services (used toanalyze blood and urine samples collected during the study includingpharmacokinetic data), eResearch Technologies (used to review digitalECG recordings), and Canfield Scientific, Inc. (used to conduct DIA offacial photographs).

The study specific Data Management Plan (DMP) defined data sources andthe data review strategy that was applied for this study. The datareview strategy ensured consistency, integrity, logical completeness andcoding of collected data. Queries were generated within the EDC tool forall discrepancies requiring investigational site follow-up. Anynecessary data corrections in EDC were made by the investigational sitepersonnel and verified by Allergan Clinical Data Management. Anynecessary data corrections for other data sources were authorized by theinvestigational site personnel and applied by the respective vendors.

Details and timing of any additional quality assessments carried out forthe study were also captured within the study specific DMP.

Following completion of all data review activities, records within theEDC tool were locked and transferred to Allergan Clinical DataManagement.

3.6.4 Clinical Quality Assurance Audits

An independent internal Quality Assurance unit conducted audits ofrandomly selected investigators and clinical data. During these audits,the study was assessed for compliance with the FDA's GCP regulations andguidelines, International Conference on Harmonisation (ICH) guidelinesfor GCP Topic E6, and applicable SOPs.

3.6.5 Investigational Site Procedures

Quality assurance activities provided by the investigational staffincluded eCRF review for accuracy and completeness and study medicationaccounting. Study center personnel were responsible for timelyprocessing of eCRFs, data clarifications, and sending corrections toAllergan.

3.6.6 Laboratory Procedures

A central laboratory, Covance Central Laboratory Services, was used toanalyze blood, urine, and plasma samples. This central clinicallaboratory is licensed under the Clinical Laboratory ImprovementAmendments and accredited by the College of American Pathology.

All blood samples drawn for pharmacokinetic analysis were stored atCovance Central Laboratory Services (Indianapolis, Ind.) until shipmentto the Covance bioanalytical laboratory (Indianapolis, Ind.). Blood wasassayed for oxymetazoline concentrations in plasma using a validatedhigh performance LC-MS/MS method. The bioanalysis of human plasmaoxymetazoline concentrations for this study was conducted in compliancewith the US FDA “Guidance for Industry: Bioanalytical Method Validation”dated May 2001. The pharmacokinetic data analysis of this study wasconducted according to applicable GCP and pertinent FDA/ICH guidelines.

3.6.7 Bioanalytical Methodology

All plasma samples collected for pharmacokinetic analysis were stored atCovance Central Laboratory Services (Indianapolis, Ind.) until shipmentto the Covance Bioanalytical Services, LLC (Indianapolis, Ind.). Plasmawas assayed for oxymetazoline concentrations using a validated LC-MS/MSmethod with an LLOQ of 10 pg/mL.

The treatment randomization code was released to Covance BioanalyticalServices in order to analyze patients on active treatment only.

The bioanalysis of human plasma oxymetazoline concentrations for thisstudy was conducted in compliance with Covance Standard OperatingProcedures and in accordance with Guidelines on Good Clinical Practice,ICH E6. The pharmacokinetic data analysis of this study was conductedaccording to applicable GCP and pertinent FDA/ICH guidelines.

3.6.8 Pharmacokinetic Data Handling and Storage

All electronic files were stored and archived on dedicated Allerganservers. Bioanalytical data files from the bioanalytical laboratorieswere provided to Allergan's Data Management and Programming group viasecure File Transfer Protocol and followed the agreed-upon Data TransferAgreement. A final analysis dataset was provided to Allergan'sPharmacokinetics and Drug Disposition Department from Allergan's DataManagement Department via UNIX. Refer to the Pharmacokinetic DataAnalysis Plan for details.

3.7 Statistical and Data Analysis Methods and Determination of SampleSize

A statistical analysis plan that expanded the statistical section of theprotocol was approved prior to locking the database. The plan,comprising text with table and listing shells, contained a detaileddescription of methods to analyze data collected in the study. Ad hocanalyses are summarized in Section 3.8. Information on thepharmacokinetic analyses can be found in the Pharmacokinetic DataAnalysis Plan and are summarized below.

3.7.1 Statistical and Analytical Plans

3.7.1.1 Analysis Populations

Three populations were utilized:

-   -   the modified intent-to-treat (mITT) population consisted of all        randomized patients who applied study medication during the        study, and had both CEA and SSA measurements at baseline (ie,        predose on day 1) and at least one post-baseline measurement for        both CEA and SSA.    -   the per protocol (PP) population consisted of randomized        patients with no major protocol violation during the study. The        PP population was determined prior to database lock.    -   the safety population consisted of patients who applied at least        1 dose of study medication in the study.

If a patient received an incorrect study medication other than intendedstudy medication as randomized, the analysis of that patient's data wasbased on the actual treatment received at baseline visit for the safetyand PP analyses and the randomized assignment for the mITT analyses.

Efficacy analyses were performed on the mITT population as the primarypopulation. Primary efficacy analyses were also performed on the PPpopulation. Safety analyses were based on the safety population.

Missing data were imputed using the last observation carried forward(LOCF) method for the mITT population. No imputation was made for the PPand Safety populations.

3.7.1.2 Primary Efficacy Analysis

The primary efficacy variable was defined as a treatment responder athours 2, 4, 6, 8, 10, and 12 on day 28. A responder was defined as atleast a 2-grade improvement from baseline on both CEA and SSA. Thebaseline value was the value collected on day 1 predose (baseline). Ifday 1 predose data were missing, screening visit data were used.

The hypotheses were as follows:

Null hypothesis: Oxy 0.5% QD and vehicle QD were equally effective inreducing erythema over a 12-hour time period on day 28 as measured bypatients with at least a 2-grade decrease (improvement) from baseline inboth CEA and SSA at hours 2, 4, 6, 8, 10, and 12.

Alternative hypothesis: Oxy 0.5% QD and vehicle QD were not equallyeffective.

The same hypotheses as stated above were formulated to compare thefollowing groups:

-   -   Oxy 0.5% BID versus vehicle BID    -   Oxy 1.0% QD versus vehicle QD    -   Oxy 1.0% BID versus vehicle BID    -   Oxy 1.5% QD versus vehicle QD    -   Oxy 1.5% BID versus vehicle BID

A generalized linear model with a logit link function and exchangeablecovariance structure using generalized estimation equations (GEE) wasperformed to analyze the primary variable at hours 2, 4, 6, 8, 10, and12 on day 28 to compare treatment difference (ie, Oxy 0.5% QD versusvehicle QD, Oxy 1.0% QD versus vehicle QD, and Oxy 1.5% QD versusvehicle QD, separately). The model included fixed effects of treatmentgroup and timepoints. If there was no responder in the vehicle arm atall timepoints that could have caused inconvergence, imputations weremade for 1 vehicle patient to be a responder at hour 2 to perform theanalysis.

Similar analyses were performed to compare each oxymetazolinetwice-daily treatment group to the vehicle twice-daily group.

The analyses were performed on both the mITT and PP populations.

3.7.1.3 Secondary Efficacy Analysis

The secondary efficacy variables were defined as follows: the proportionof patients with at least a 2-grade decrease (improvement) on both CEAand SSA from baseline at hour 0.5 post-dose on day 28; and theproportion of patients with at least a 2-grade decrease (improvement) onboth CEA and SSA from baseline at hour 1 post-dose on day 28.

A frequency distribution of patients with at least a 2-grade decrease(improvement) on both CEA and SSA by timepoint (hours 0.5 and 1) on day28 and treatment group was tabulated. A 2-sided 90% confidence interval(CI) for the treatment difference (ie, each active treatment minusvehicle) by timepoint was provided using a normal approximation method.A Pearson's chi-square test was used to test the treatment difference.If 25% or more of the cells had expected counts less than 5, a Fisher'sexact test was used. The same analyses were performed for days 1 and 14.

In addition, a frequency distribution of primary variable by treatmentgroup was tabulated. A 2-sided 90%. CI for the treatment difference (ie,Oxy 0.5% QD minus vehicle QD, Oxy 1.00% a QD minus vehicle QD, Oxy 1.5%QD minus vehicle QD, separately) of primary variable was provided usinga normal approximation method.

The same statistical method used in the primary efficacy analysis wasused to analyze the primary variable between 2 active treatment groups(eg, Oxy 1.5% QD versus Oxy 0.5% QD). The same analyses were performedfor the difference between 2 active twice-daily treatment groups and forthe difference between one once-daily and one twice-daily treatmentgroup (eg, Oxy 0.5% BID and Oxy 1.0% QD).

3.7.1.4 Other Efficacy Analyses

Other efficacy variables were defined as follows:

-   -   proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline at hours 2, 4,        6, 8, 10, and 12 on day 14    -   proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline at hours 2, 4,        6, 8, 10, and 12 on day 1    -   proportion of patients with at least a 1-grade decrease        (improvement) on both CEA and SSA from baseline at hours 2, 4,        6, 8, 10, and 12 on day 1. The same definition was used for days        14 and 28    -   proportion of patients with at least a 1-grade decrease        (improvement) on CEA from baseline at hours 2, 4, 6, 8, 10, and        12 on day 1. The same definition was used for days 14 and 28.    -   proportion of patients with at least a 1-grade decrease        (improvement) on SSA from baseline at hours 2, 4, 6, 8, 10, and        12 on day 1. The same definition was used for days 14 and 28.    -   proportion of patients with at least a 1-grade improvement on        each question of the PRO from baseline on day 28. The PRO        measures were:        -   Symptom Assessment for Rosacea Facial Redness        -   Impact Assessment for Rosacea Facial Redness        -   Satisfaction Assessment for Rosacea Facial Redness

The same statistical method used for the primary variable was used forall other efficacy variables, except for PRO variables. For the PROvariables, frequency distributions of the PRO variables were tabulatedby visit. A 2-sided 90% CI for the treatment difference (ie, each activetreatment group minus vehicle group) was provided using a normalapproximation method. A Pearson's chi-square test was used to test thetreatment difference. If 25% or more of the cells have expected countsless than 5, a Fisher's exact test was used. Raw PRO data was summarizedusing a frequency distribution by treatment group and visit. The numberof patients with at least a 1-grade improvement in each PRO question andnumber of patients who reported “very satisfied/satisfied” versus“neither satisfied nor dissatisfied/dissatisfied/very dissatisfied” wasanalyzed in the same manner.

Raw data and change from baseline in CEA, SSA, and PRO questions weresummarized using descriptive statistics by timepoint and treatmentgroup. Frequency distributions were used to summarize raw CEA, SSA, andPRO data by treatment group.

3.7.1.5 Pharmacokinetic Analysis

3.7.1.5.1 Treatment of Below the Lower Limit of Quantitation Data

For descriptive statistics of oxymetazoline plasma concentrations, thebelow the lower limit of quantitation (BLQ) values were set to zero andcalculation of mean concentrations in the presence of BLQ value(s) wereperformed according to SOP DSEPK-002.

3.7.1.5.2 Pharmacokinetic Parameters

The calculation of pharmacokinetic parameters and graphing was performedusing Phoenix WinNonlin 6.3 (Mountain View, Calif.). Data cleaning,management, and summary statistics were performed using SAS for WindowsVersion 9.2 (Cary, N.C.). The following pharmacokinetic parameters werecalculated using a non-compartmental analysis, whenever possible:

-   -   C_(max)=maximum observed plasma concentration    -   T_(max)=time corresponding to maximum observed plasma        concentration    -   AUC_(0-t)—Area under the plasma concentration-time curve from        time 0 to time t    -   R₀=accumulation ratio calculated as

$\frac{{AUC}_{0 - {\tau{({{DAY}\mspace{14mu} 28})}}}}{{AUC}_{0 - {\tau{({{DAY}\mspace{14mu} 1})}}}}$where τ represents the dosing interval

-   -   T_(eff)=effective half-life calculated as

$\frac{\ln\mspace{11mu} 0.5 \times \tau}{\ln\mspace{11mu}\left( {1 - \frac{1}{R_{0}}} \right)}$where τ represents the dosing interval3.7.1.5.3 Statistical Analysis

Descriptive statistics (mean, standard deviation, etc.) were calculatedfor plasma oxymetazoline concentrations and for the calculatedpharmacokinetic parameters.

3.7.1.6 Other Measures Analyses

3.7.1.6.1 Subject Self-Assessment for Rosacea Facial Redness

Subject self-assessment for rosacea facial redness (SSA-2) wasadministered at the same timepoints as the SSA and CEA. All analysesperformed for the SSA were performed for the SSA-2.

In addition, a paired t-test was used to compare change from baseline inSSA and SSA-2 by timepoint and treatment group. Analysis of thecorrelation was performed based on pooled treatment groups at eachtimepoint and all timepoints combined using a Spearman correlationcoefficient and its 90% CI. The analyses included raw data between CEAand SSA, between CEA and SSA-2, and between SSA and SSA-2. The sameanalyses were performed for change from baseline data.

3.7.1.6.2 Clinician Telangiectasia Assessment

Clinician Telangiectasia Assessment (CTA) was performed by theinvestigator per the timepoints specified in Table 3-2. A frequencydistribution of the CTA was performed by treatment group, and timepoint.A shift table of each category at baseline was compared to those at eachscheduled timepoint/visit. Baseline was defined as the predosemeasurement on day 1. If the day −1 data were not available, thescreening data were used as baseline.

3.7.1.6.3 Lesion Count

Lesion count of the face was performed by the investigator at screening,days 1, 14, 28, 35, and 56. Analysis of change from baseline on thelesion count was performed using descriptive statistics. Baseline wasdefined as the predose measurement on day 1. If the day −1 data were notavailable, the screening data were used as baseline. Raw data weresummarized by descriptive statistics by treatment group.

3.7.1.6.4 Aesthetic Questionnaire

All questions of the AQ were assessed on day 14 and the questionnaireabout the characteristics of the study medication was assessed again onday 28. Frequency distributions were used for all questions in the AQ.Questions 6a and 6c on day 14, and questions on day 28 were dichotomizedby pooling scale from 1 to 4 as one group (such as “not important” or“less favorable”) and 5 to 9 as a separate group (such as “moreimportant” or “more favorable”) and these were summarized by frequencydistribution.

3.7.1.6.5 Digital Image Analysis

Facial photographs of patients in treatment groups 1, 2, 3, and 4(once-daily dosing) were taken at predose, 6, and 12 hours postdose ondays 1, 14, 28, and 35. An average of data from the 3 views ofphotographs (ie, right view, frontal view, and left view) were taken torepresent the measurement at that timepoint. A separate exploratoryanalysis plan was provided by Canfield Scientific, Inc. for theexploratory analyses of DIA data (see Analysis Plan—Canfield ExploratoryAnalysis).

The following 6 measurements were performed using Canfield proprietaryalgorithms, with the analysis variables defined accordingly:

-   -   Fractional Area: defined as the percentage of the masked area        occupied by redness. The masked area was defined as the area        within which the analysis took place in pixels, which was then        converted to millimeter square.    -   Erythema Severity: defined as the mean normalized fractional        area and erythema contrast    -   Erythema Redness: defined as the percent of erythema redness        within the mask redness in the RBX-Red image ([Mean Erythema        Redness/Mean Mask Redness]*100%)    -   Erythema Contrast: defined as (Mean Erythema Redness/Mean        Background Redness in the RBX-Red image)    -   Intensity of Erythema: defined as percent intensity of erythema        within the mask Intensity (Mean Intensity of Erythema/Mean Mask        Intensity in a cross-polarized image)*100%)    -   Erythema Visibility: defined as (Mean Intensity of Erythema/Mean        Background Intensity in a cross-polarized image)        3.7.1.6.6 Subgroup Analyses of Efficacy Variables

The primary efficacy variable was analyzed by age group (<45, 45 to 64,and ≥65 years old) and sex (male versus female) to compare eachoxymetazoline group to its vehicle using the same statistical methodsdescribed in Section 3.5.1.1.

3.7.1.7 Safety Analysis

3.7.1.7.1 Treatment Exposure

Patient exposure to the study medication was characterized by studyduration, treatment duration, and weight of study medication applied topatients. Study duration was defined as number of days from the date offirst dosing to study exit; if the date of exit was missing, the date ofthe last visit was used (ie, date of study visit minus date of firstdosing plus 1). Treatment duration was defined as number of days fromthe date of first dosing to last dose (ie, date of last dose minus dateof first dose plus 1). Weight of study medication was calculated basedon tube weight at postdose (after evening dose for twice-daily patients)minus tube weight at predose on each days 1, 2, 14, and 28. Studyduration and treatment duration were summarized using descriptivestatistics by treatment group, by total for each dosing regimen, and byoverall total. Weight of study medication was summarized using studymedication by treatment group and by total for each dosing regimen.

3.7.1.7.2 Adverse Events

Adverse events were coded using preferred terms and primary System OrganClass (SOC) from the Medical Dictionary for Regulatory Activities(MedDRA), version 15.1. Adverse events were collected both for thescreening/baseline period (which were referred to as pretreatmentadverse events [PTAEs]) and for the study period after treatment wasinitiated (which were referred to as postbaseline adverse events; ie,adverse events with start date from study day 1 through study exit). Atreatment emergent adverse event (TEAE) was defined a postbaselineadverse event where there was no PTAE of the same MedDRA preferred termor the maximum severity during the postbaseline period was more severethan the maximal severity of any PTAE of the same MedDRA preferred term.

For each preferred term, the incidence of TEAEs was presented andsummarized on a per-patient basis as follows:

-   -   by preferred term in descending order of incidence rate    -   by primary SOC in alphabetical order, and preferred term    -   by primary SOC in alphabetical order, preferred term, and        severity (maximum severity)

The maximum severity of a TEAE experienced by a patient was determinedby the most severe rating recorded on the eCRF for the patient's givenTEAE. The incidence of TEAEs was provided for all TEAEs regardless ofcausality and for treatment-related TEAEs.

Incidences of adverse events were summarized by treatment groups as wellas by total of each regimen and by oxymetazoline versus vehicle.

TEAEs leading study discontinuation, and treatment-related TEAEs leadingstudy discontinuation were summarized by preferred term within primarySOC.

A patient listing was generated for TEAEs, including patient age, sex,and race, sorted by primary SOC, preferred term, onset and stop date,onset day relative to the most recent dose, relationship, and severity.

Serious TEAEs, as well as pretreatment serious adverse events weresummarized by preferred term within primary SOC. A listing of seriousTEAEs and pretreatment serious adverse events was presented. Inaddition, treatment-related serious TEAEs were summarized by preferredterm within primary SOC.

3.7.1.7.3 Facial Dermal Tolerability Assessment

Facial dermal tolerability assessment were evaluated by investigatorsand patients on days 1 (pre-dose, hours 1, 2, 4, 6, 8, 10, and 12), 2(predose), 14 (predose, hours 1, 2, 4, 6, 8, 10, and 12), 28 (pre-dose,hours 1, 2, 4, 6, 8, 10, and 12), 35, and 56. Investigator's assessmentsincluded dryness and scaling and patient's assessment includedstinging/burning, and pruritus; each had 4-point scales: 0=none, 1=mild,2=moderate, 3=severe.

The number and percent of patients with at least a 1 severity increase(worsening) from baseline for 1 or more visits was generated bytreatment group for day 1, day 14, day 28, and from day 1 through day28. Raw values were summarized using shift tables and frequencydistributions by treatment group. In addition, analyses of raw valuesand change from baseline at post-baseline timepoints and visits wereperformed using descriptive statistics. Baseline was the pre-doseassessment on day 1.

3.7.1.7.4 Clinical Laboratory Evaluations

Each applicable laboratory variable (hematology, blood serum chemistry,urinalysis), except those that had only a few categories of response,was summarized for each measurement day for the change from baseline.Laboratory values were categorized as low, normal, and high according tothe reference normal range. For each variable, a shift table oflow/normal/high values at baseline was compared to those at eachscheduled visit for laboratory tests after baseline visit. A listing bypatient of all abnormal (low or high as described above) laboratoryvalues was provided.

3.7.1.7.5 Vital Signs

Data for systolic and diastolic blood pressure (mm Hg), pulse rate(beats/minute), respiratory rate (breaths/minute) and body temperature(° C.) were summarized by treatment groups. Change from baseline wassummarized using descriptive statistics. Baseline values were defined asthe last non-missing measurement prior to the first application of studymedication on day 1.

3.7.1.7.6 Physical Examination

Physical examination values for each body system were categorized asnormal or abnormal, and were summarized. A listing by patient of allabnormal physical examination values was provided.

3.7.1.7.7 Electrocardiogram

ECG variables included heart rate, QRS duration, QT interval, QTcB (QTcorrected using the Bazett's correction), QTcF (QT corrected using theFridericia's correction), RR interval, and PR interval. The raw valuesand change from baseline values for ECG variables were summarized bytreatment group. All ECG assessment results from the central readingcenter (ERT) were presented in the data listings. Baseline was definedas the last non-missing measurement prior to the first dosing of studymedication.

3.7.1.7.8 Pregnancy Test Results

Pregnancy test results for female patients of childbearing potentialwere provided in a data listing.

3.7.1.7.9 Subgroup Analyses for Safety Variables

There was no subgroup analysis for safety variables.

3.7.2 Determination of Sample Size

Sample size was determined empirically and power analyses were performedbased on the day 1 results from Study 199201-001 using simulations. Theassumptions for simulations were:

-   -   a sample size of 40 patients per treatment arm (taking 10%        attrition rate of 45 enrolled patients)    -   2-sided alpha of 0.05    -   a responder was defined as a patient with at least a 2-grade        improvement from baseline on both CEA and SSA scales    -   analysis timepoints were hours 2, 4, 6, 8, 10, and 12    -   assumed responder rates:        -   responder rates obtained after a single application of            oxymetazoline 1.5%, 1.0%, and 0.5% on day 1 in Study            199201-001 as shown in Table 3-3        -   responder rates for vehicle were assumed to be 10.0%, 4.0%,            4.0%, 4.0%, 4.0%, and 4.0% for hours 2, 4, 6, 8, 10, and 12,            respectively, as the actual responder rate was 0.0% across            all timepoints in Study 199201-001    -   a generalized linear model with a logit link function using GEE        was performed 1000 times

TABLE 3-3 Power Calculations to Compare Oxymetazoline 1.5%, 1.0%, and0.5% to Vehicle Responder Rates from Study 199201-001 Hour 2 Hour 4 Hour6 Hour 8 Hour 10 Hour 12 Power Oxymetazoline 1.5% 31.3% 37.5% 28.1% 9.4%12.5% 6.3% 99.9% Oxymetazoline 1.0% 31.3% 34.4% 21.9% 9.4% 6.3% 3.1%99.8% Oxymetazoline 0.5% 12.5% 18.8% 15.6% 9.4% 9.4% 6.3% 79.7% Vehicle10.0% 4.0% 4.0% 4.0% 4.0% 4.0%3.8 Changes in the Conduct of the Study or Planned Analyses

The study database was locked and the study unblinded on 12 Jul. 2013.No individual patients were unblinded during the study.

Note, there were 2 intended analyses that were described incorrectly inthe statistical analysis plan, but were performed as intended:

-   -   The intended analysis of the proportion of patients with at        least a 2-grade decrease (improvement) on both CEA and SSA-2        from baseline at hours 2, 4, 6, 8, 10, and 12 on days 1, 14, and        28 was described incorrectly in the statistical analysis plan as        the proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline.    -   The intended analysis of the proportion of patients with at        least a 1-grade decrease (improvement) on both CEA and SSA from        baseline at hours 2, 4, 6, 8, 10, and 12 on days 1, 14, and 28)        was described incorrectly in the statistical analysis plan as        the proportion of patients with at least a 2-grade decrease        (improvement) on both SSA from baseline.        3.8.1 Changes in the Conduct of the Study

The protocol was approved on 29 Oct. 2012. There were no amendments tothe protocol. The study was conducted as planned.

3.8.2 Changes to Analyses Prior to Database Lock

Prior to database lock, there were no changes made to the analyses inthe statistical analysis plan versus those in the approved protocol.

3.8.3 Changes to Analyses Following Database Lock

No changes were made to the statistical analysis plan following databaselock. The following post hoc analyses were performed and summarized inthe clinical study report:

-   -   proportion of patients with at least a 2-grade decrease        (improvement) on both CEA and SSA from baseline during        posttreatment period (days 29 to 56)    -   proportion of patients with rebound/worsening of erythema on        both CEA and SSA during posttreatment period    -   subgroup efficacy analyses by CEA and SSA score at baseline    -   analysis of TEAEs that occurred during the treatment period and        posttreatment period

Additional post hoc exploratory analyses were made.

4. Results—Study Patients

4.1 Disposition of Patients

The first patient entered the study on 20 Dec. 2012 and the last patientexited the study on 3 Jun. 2013.

A total of 357 patients were enrolled and randomized into the study. Onepatient was randomized by error; this patient did not receive studytreatment and was not included in the analysis populations. Therefore,356 patients were included in the mITT and safety populations. Thetreatment groups were evenly distributed, with 179 patients randomizedto the twice-daily treatment group (135 Total Oxy and 44 vehicle), and177 patients randomized to the once-daily treatment group (133 Total Oxyand 44 vehicle). Patient allocation to each treatment group and theirsubsequent disposition is summarized in Table 4-1.

A majority of patients (95.2% [339/356]) completed the study. In thetwice-daily treatment group, 6.7% (9/135) of the Oxy patients and 4.5%(2/44) of the vehicle patients discontinued the study. In the once-dailytreatment group, 3.0% (4/133) of the Oxy patients and 4.5% (2/44) of thevehicle patients discontinued the study. The primary reason fordiscontinuation from the study was adverse events in 2.8% (10/356) ofall patients: 4.4% (6/135) in the Total Oxy twice-daily group versus2.3% (1/44) in the vehicle BID group, and 1.5% (2/133) in the Total Oxyonce-daily group versus 2.3% (1/44) in the vehicle once-daily group.These adverse events are further discussed in Section 6.3.3. Otherreasons for study discontinuation are summarized in Table 4-1.

TABLE 4-1 Patient Disposition and Exit Status (mITT Population) Number(%) of Patients Oxy Oxy Oxy Total Oxy Oxy Oxy Total 1.5% 1.0% 0.5% OxyVehicle Total 1.5% 1.0% 0.5% Oxy Vehicle Total Overall Disposition BIDBID BID BID BID BID QD QD QD QD QD QD Total Enrolled 45 45 45 135 44 17944 44 45 133 44 177 356 Completed 42 40 44 126 42 168 44 43 42 129 42171 339 (93.3) (88.9) (97.8) (93.3) (95.5) (93.9) (100.0) (97.7) (93.3)(97.0) (95.5) (96.6) (95.2) Discontinued 3 (6.7)  5 (11.1) 1 (2.2) 9(6.7) 2 (4.5) 11 (6.1)  0 (0.0) 1 (2.3) 3 (6.7) 4 (3.0) 2 (4.5) 6 (3.4)17 (4.8)  Adverse 2 (4.4) 3 (6.7) 1 (2.2) 6 (4.4) 1 (2.3) 7 (3.9) 0(0.0) 1 (2.3) 1 (2.2) 2 (1.5) 1 (2.3) 3 (1.7) 10 (2.8)  Event Lack of 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) Efficacy Pregnancy 0 (0.0) 0 (0.0) 0 (0.0)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)0 (0.0) Lost to 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Follow-up Personal 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.2) 1(0.8) 0 (0.0) 1 (0.6) 1 (0.3) Reasons Protocol 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.2) 1 (0.8) 0 (0.0) 1 (0.6) 1(0.3) Violation Other^(a) 1 (2.2) 2 (4.4) 0 (0.0) 3 (2.2) 1 (2.3) 4(2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3) 1 (0.6) 5 (1.4) BID =twice daily; mITT = modified intent-to-treat; Oxy = oxymetazolinehydrochloride; QD = once daily4.2 Protocol Deviations

The master protocol deviation list contains all deviations from thestudy protocol for all study sites in all geographic regions. The masterlist was compiled prior to database lock based on data review and studymonitoring activities. The complete list is included in the trial masterfile and is available upon request. Most deviations were minor and didnot affect the study conduct or interpretation of the study results.

Using prespecified criteria developed during blinded data review andprior to data base lock, each deviation in the master list wasclassified as “non-significant” or “significant.” Significant deviationswere related to collection of study data, source documentation,treatment visit compliance, informed consent/privacy, study procedures,use of prohibited concomitant medication or procedure, administration ofstudy drug, and SSA assessment or compliance. Non-significant deviationswere related to items that were likely not to substantially affect theconduct and assessment of patient data in the study, eg, study visits orprocedures not occurring on time.

A total of 55 patients had significant protocol deviations that wereidentified prior to database lock; these are listed below. There couldhave been more than one type of significant protocol deviation for apatient (ie, 7 patients had more than one type of significant protocoldeviation).

-   -   incorrect version of informed consent form (ICF) signed by        patient prior to study; ICF or patient privacy authorization not        completed appropriately; study procedures were completed prior        to patient signing the ICF (15 patients)    -   source documentation was missing, incomplete, incorrect, or not        reviewed appropriately (14 patients)    -   pharmacokinetic laboratory sample was not collected (14        patients)    -   visit compliance (10 patients)    -   study procedure was not performed, not performed as specified,        or performed by staff without appropriate delegation,        authorization, or training (3 patients)    -   use of prohibited medication or procedure (2 patients)    -   patient missing at least 4 consecutive days of study drug (2        patients)    -   SSA assessment not “more redness than I prefer” or “completely        unacceptable redness” by the patient (1 patient)    -   SSA and SSA-2 compliance (1 patient)

There were 18 patients excluded from analyses of the PP population. Theprimary reason for exclusion was due to patients missing at least 25% (7days) of any study treatment days out of 28 days (14 patients). Otherreasons included patients missing at least 4 consecutive days of studydrug (2 patients), use of prohibited medication or procedure confoundingstudy evaluation (1 patient), and SSA assessment not “more redness thanI prefer” or “completely unacceptable redness” by the patient (1patient).

One patient (10013-1189) in the Oxy 0.5% QD group discontinued the studydue to a protocol violation of not complying with the visit schedule.

4.3 Datasets Analyzed

The mITT population, which consisted of all randomized patients whoapplied study medication during the study, and had both CEA and SSAmeasurements at baseline (ie, predose on day 1) and at least onepostbaseline measurement for both CEA and SSA, included 356 patients(179 in the twice-daily treatment groups and 177 in the once-dailytreatment groups) (Table 4-1).

The PP population, which consisted of randomized patients with no majorprotocol violation(s) during the study, included 338 patients (167 inthe twice-daily treatment groups and 171 in the once-daily treatmentgroups).

The safety population, which consisted of patients who applied at least1 dose of study medication in the study, was identical to the mITTpopulation.

4.4 Demographics and Other Baseline Characteristics

4.4.1 Demographics

Demographics overview is presented in

Table 4-2. The demographic variables were similar across all treatmentgroups. The mean age of the patients was 50.0 years (range 19 to 79years). The largest proportion of patients (60.4%) was aged between 45and 64 years of age, with 29.5% being <45 years of age, and 10.1% being≥65 years of age.

There were more females than males (80.1% versus 19.9%), and themajority of the population was Caucasian (91.3%). The mean weight was87.3 kg (range 46 to 162 kg), and the mean height was 166.4 cm (range135 to 191 cm).

Per the inclusion criteria, all patients had CEA and SSA grades of 3 orhigher at baseline, demonstrating moderate to severe facial erythema,with the exception of 1 patient. Patient 10001-1342 in the Oxy 0.5% BIDgroup had an SSA grade of 2, which was considered to be a major protocoldeviation (see Section 4.2). A total of 82.00/% (292/356) of patientshad CEA grade 3 and 18.0% (64/356) of patients had CEA grade 4 atbaseline, while 70.8% (252/356) of patients had SSA grade 3 and 28.9%(103/356) of patients had SSA grade 4 at baseline.

The demographics of the PP population were similar to those of the mITTpopulation, and the safety population was identical to the mITTpopulation. The mITT population was used for the pharmacokineticanalysis.

TABLE 4-2 Baseline Demographics (mITT Population) Oxy 1.5% Oxy 1.0% Oxy0.5% Vehicle Oxy 1.5% Oxy 1.0% Oxy 0.5% BID BID BID BID QD QD QDCharacteristic Attribute (N = 45) (N = 45) (N = 45) (N = 44) (N = 44) (N= 44) (N = 45) Age N 45 45 45 44 44 44 45 (yrs) Mean 45.9 51.0 48.1 53.051.2 51.3 49.6 SD 12.80 10.77 10.64 13.34 11.05 12.09 10.36 Median 48.050.0 48.0 54.0 50.5 50.5 53.0 Min 19 23 23 21 23 27 21 Max 69 71 69 7976 74 65 (n [%])  <45 16 (35.6) 11 (24.4) 16 (35.6)  9 (20.5) 10 (22.7)15 (34.1) 14 (31.1) 45 to 64 27 (60.0) 29 (64.4) 26 (57.8) 28 (63.6) 28(63.6) 23 (52.3) 30 (66.7) ≥65 2 (4.4)  5 (11.1) 3 (6.7)  7 (15.9)  6(13.6)  6 (13.6) 1 (2.2) Sex N 45 45 45 44 44 44 45 (n [%]) Male  9(20.0) 11 (24.4) 4 (8.9) 11 (25.0) 11 (25.0)  9 (20.5) 10 (22.2) Female36 (80.0) 34 (75.6) 41 (91.1) 33 (75.0) 33 (75.0) 35 (79.5) 35 (77.8)Race N 45 45 45 44 44 44 45 (n [%]) Caucasian 39 (86.7) 42 (93.3) 42(93.3) 40 (90.9) 38 (86.4) 40 (90.9) 43 (95.6) Black 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 1 (2.3) 0 (0.0) 0 (0.0) Hispanic  6 (13.3) 3 (6.7) 3 (6.7)4 (9.1)  5 (11.4) 4 (9.1) 2 (4.4) Other 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)0 (0.0) 0 (0.0) 0 (0.0) Caucasian 39 (86.7) 42 (93.3) 42 (93.3) 40(90.9) 38 (86.4) 40 (90.9) 43 (95.6) Non-  6 (13.3) 3 (6.7) 3 (6.7) 4(9.1)  6 (13.6) 4 (9.1) 2 (4.4) Caucasian CEA^(a) N 45 45 45 44 44 44 45(n [%]) Grade 0 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)Grade 1 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 20 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 3 33(73.3) 37 (82.2) 38 (84.4) 40 (90.9) 38 (86.4) 34 (77.3) 37 (82.2) Grade4 12 (26.7)  8 (17.8)  7 (15.6) 4 (9.1)  6 (13.6) 10 (22.7)  8 (17.8)SSA^(a) N 45 45 45 44 44 44 45 (n [%]) Grade 0 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 1 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) Grade 2 0 (0.0) 0 (0.0)  1 (2.2)^(b) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) Grade 3 34 (75.6) 32 (71.1) 31 (68.9) 28 (63.6) 30(68.2) 36 (81.8) 28 (62.2) Grade 4 11 (24.4) 13 (28.9) 13 (28.9) 16(36.4) 14 (31.8)  8 (18.2) 17 (37.8) Weight N 44 45 45 44 44 44 45 (kg)Mean 87.7 90.5 82.6 84.3 91.6 88.6 86.3 SD 17.39 19.20 22.12 18.83 19.6424.79 16.82 Median 85.0 88.0 77.0 83.0 89.0 84.0 84.0 Min 57 50 52 52 5346 52 Max 136 135 151 123 135 162 120 Height N 44 45 45 44 44 44 45 (cm)Mean 165.1 167.8 165.5 167.1 168.5 165.8 166.9 SD 8.38 11.20 8.10 9.798.42 10.30 9.78 Median 165.0 166.0 164.0 165.0 167.5 168.0 165.0 Min 140135 152 147 152 142 140 Max 183 191 185 191 191 191 189 Vehicle TotalOxy Total Oxy Total Total Overall QD BID QD Oxy Vehicle TotalCharacteristic Attribute (N = 44) (N = 135) (N = 133) (N = 268) (N = 88)(N = 356) Age N 44 135 133 268 88 356 (yrs) Mean 50.2 48.3 50.7 49.551.6 50.0 SD 11.26 11.55 11.13 11.38 12.36 11.65 Median 48.5 49.0 51.050.0 50.0 50.0 Min 22 19 21 19 21 19 Max 75 71 76 76 79 79 (n [%])   <4514 (31.8) 43 (31.9) 39 (29.3) 82 (30.6) 23 (26.1) 105 (29.5)  45 to 6424 (54.5) 82 (60.7) 81 (60.9) 163 (60.8)  52 (59.1) 215 (60.4)  ≥65  6(13.6) 10 (7.4)  13 (9.8)  23 (8.6)  13 (14.8) 36 (10.1) Sex N 44 135133 268 88 356 (n [%]) Male  6 (13.6) 24 (17.8) 30 (22.6) 54 (20.1) 17(19.3) 71 (19.9) Female 38 (86.4) 111 (82.2)  103 (77.4)  214 (79.9)  71(80.7) 285 (80.1)  Race N 44 135 133 268 88 356 (n [%]) Caucasian 41(93.2) 123 (91.1)  121 (91.0)  244 (91.0)  81 (92.0) 325 (91.3)  Black 0(0.0) 0 (0.0) 1 (0.8) 1 (0.4) 0 (0.0) 1 (0.3) Hispanic 3 (6.8) 12 (8.9) 11 (8.3)  23 (8.6)  7 (8.0) 30 (8.4)  Other 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) Caucasian 41 (93.2) 123 (91.1)  121 (91.0)  244(91.0)  81 (92.0) 325 (91.3)  Non- 3 (6.8) 12 (8.9)  12 (9.0)  24 (9.0) 7 (8.0) 31 (8.7)  Caucasian CEA^(a) N 44 135 133 268 88 356 (n [%])Grade 0 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 1 0 (0.0)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 2 0 (0.0) 0 (0.0) 0 (0.0)0 (0.0) 0 (0.0) 0 (0.0) Grade 3 35 (79.5) 108 (80.0)  109 (82.0)  217(81.0)  75 (85.2) 292 (82.0)  Grade 4  9 (20.5) 27 (20.0) 24 (18.0) 51(19.0) 13 (14.8) 64 (18.0) SSA^(a) N 44 135 133 268 88 356 (n [%]) Grade0 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 1 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Grade 2 0 (0.0) 1 (0.7) 0 (0.0) 1(0.4) 0 (0.0) 1 (0.3) Grade 3 33 (75.0) 97 (71.9) 94 (70.7) 191 (71.3) 61 (69.3) 252 (70.8)  Grade 4 11 (25.0) 37 (27.4) 39 (29.3) 76 (28.4) 27(30.7) 103 (28.9)  Weight N 44 134 133 267 88 355 (kg) Mean 86.8 87.088.8 87.9 85.5 87.3 SD 17.90 19.81 20.61 20.20 18.31 19.75 Median 87.584.0 87.0 85.0 86.0 86.0 Min 48 50 46 46 48 46 Max 131 151 162 162 131162 Height N 44 134 133 267 88 355 (cm) Mean 164.8 166.2 167.0 166.6166.0 166.4 SD 7.64 9.35 9.53 9.43 8.81 9.27 Median 164.0 165.0 166.0165.0 165.0 165.0 Min 152 135 140 135 147 135 Max 185 191 191 191 191191 BID = twice daily; CEA = Clinician's Erythema Assessment scale; Oxy= oxymetazoline hydrochloride; QD = once daily; SSA = SubjectSelf-Assessment of Erythema ^(a)CEA and SSA were measured predose onday 1. ^(b)Patient 10001-1342 had an SSA grade of 2, which wasconsidered to be a major protocol deviation (see Section 4.2).4.4.2 Medical History

The most common patient medical histories (occurring in >20% of allpatients), other than those coding to the MedDRA SOC of Skin andSubcutaneous Tissue Disorders, mapped to the MedDRA SOCs of ImmuneSystem Disorders (33.1% [118/356]), Vascular Disorders (27.5% [98/356]),Metabolism and Nutrition Disorders (25.0% [89/356]), SocialCircumstances (24.2% [86/356]), and Musculoskeletal and ConnectiveTissue Disorders (22.2% [79/356]). There were no clinically meaningfuldifferences among the treatment groups for any medical history term.

4.4.3 Prior and Concomitant Medications

A total of 80.3% (286/356) of all patients used medications prior tostudy entry. The most frequently used prior medications (in >10% of allpatients) were used for surgical and medical procedures (44.1%[157/356]); of these, the most commonly used was plain multivitamins(11.2% [40/356]). The only other medications that were taken by >10% ofall patients were intravaginal contraceptives (11.0% [39/356]); allother prior medications were used in <10% of patients overall.

Details of medications that were prohibited for the duration of thestudy are provided in Section 3.4.7.

The most commonly used concomitant medications (in >10% of all patients)during the study were intravaginal contraceptives (11.0% [39/356]) andplain multivitamins (10.7% [38/356]). All other concomitant medicationswere used in <10% of patients overall.

4.5 Treatment Compliance

As described in Section 3.4.8, the investigator was instructed to keepan accurate accounting of the number of investigational units receivedfrom Allergan, dispensed to the patients, the number of units returnedto the investigator by the patient, and the number of units returned toAllergan during and at the completion of the study.

Additionally, the study medication tubes were weighed predose andpostdose at each in-clinic treatment visit. Per the study protocol, thepatient was instructed to apply approximately a pea size amount ofoxymetazoline cream 0.5%, 1.0%, 1.5%, or vehicle to the face once ortwice a day, based on the randomization assignment, for 28 consecutivedays. A pea size amount of the study medication representedapproximately 0.5 grams of the product. At each visit, the weights ofstudy medication were consistent across the twice-daily and once-dailytreatment groups, with an overall weight of approximately 0.3 grams perapplication.

5. Efficacy, Health Outcomes, Pharmacokinetics, and Other MeasuresEvaluation

5.1 Analysis of Efficacy

5.1.1 Primary Efficacy Analysis: Composite of Clinicians ErythemaAssessment and Subject Self Assessment of Erythema Scale

Treatment Period

On day 1, the proportions of patients with at least a 2-grade decrease(improvement) from baseline over a 12-hour period for both the CEA andSSA were significantly greater than vehicle in the Oxy 1.5%, 1.0%, and0.5% BID treatment groups and the Oxy 1.5% and 1.0% QD treatment groups(Table 5-1). Statistically significant differences compared with vehiclewere seen starting at hour 2 on day 1 for the Oxy 1.5% BID, Oxy 1.0%BID, and Oxy 1.5% QD treatment groups, and at hour 4 on day 1 for theOxy 1.0% QD treatment group.

Treatment response was maintained through day 14 (Table 5-1). Theproportions of patients with at least a 2-grade improvement frombaseline at hour 12 on day 14 for both the CEA and SSA scales followingtwice-daily dosing were 13.3%, 17.8% and 8.9% with Oxy 1.5%, 1.0%, and0.5%, respectively, compared to 4.5% with vehicle. There was astatistically significant difference between Oxy 1.0% BID and vehicleover the 12-hour period (p=0.015). Following once-daily dosing, theproportions of patients with at least a 2-grade improvement frombaseline at hour 12 on day 14 were 6.8%, 4.5% and 6.7% with Oxy 1.5%,1.0%, and 0.5%, respectively, compared to 6.8% with vehicle. There wereno statistically significant between-group differences in any Oxytreatments compared to vehicle treatments over the 12-hour period.

On day 28 following twice-daily dosing in the mITT population, the Oxy1.5% and 1.0% treatment groups showed a statistically significantreduction in facial erythema, as defined by the proportion ofresponders, ie, patients with at least a 2-grade decrease (improvement)from baseline over a 12-hour period on both the CEA and SSA scalescompared with vehicle (Table 5-1; Table 5-2). There was no statisticallysignificant difference between Oxy 0.5% and vehicle.

Statistically significant differences compared with the vehicle groupwere observed starting at hour 4 in the Oxy 1.5% BID group and at hour 8in the Oxy 1.0% BID group. Significant between-group differences werenot observed at individual timepoints for Oxy 0.5% versus vehicle giventwice-daily. The proportions of responders in the twice-daily treatmentgroups at hour 4 (peak timepoint) on day 28 were 22.2%, 20.0% and 11.1%with Oxy 1.5%, 1.0%, and 0.5%, respectively, compared to 6.8% withvehicle. The proportions of responders in the twice-daily treatmentgroups were maintained at hour 12 on day 28, with 15.6%, 11.1% and 13.3%in the Oxy 1.5%, 1.0%, and 0.5% groups, respectively, compared to 4.5%in the vehicle group.

Following once-daily dosing in the mITT population, all 3 Oxy treatmentgroups of 1.5%, 1.0%, and 0.5% demonstrated a statistically significantreduction in facial erythema over a 12-hour period on day 28 comparedwith vehicle (Table 5-1; Table 5-2).

Statistically significant differences compared with the vehicle groupwere observed starting at hour 2 in the Oxy 1.5% QD group and at hour 4in the Oxy 1.0% QD group. Significant between-group differences were notobserved at individual timepoints for Oxy 0.5% QD versus vehicle QD. Theproportions of responders in the once-daily treatment groups at hour 4(peak timepoint) on day 28 were 27.3%, 31.8% and 17.8% with Oxy 1.5%,1.0%, and 0.5%, respectively, compared to 4.5% with vehicle. Theproportions of responders in the once-daily treatment groups weremaintained at hour 12 on day 28, with 13.6%, 13.6%, and 13.3% in the Oxy1.5%, 1.0%, and 0.5% groups, respectively, compared to 2.3% in thevehicle group.

Similar results were observed in the PP population, whereby the Oxy 1.5%and 1.0% BID treatment groups and the Oxy 1.5%, 1.0%, and 0.5% QDtreatment groups demonstrated a statistically significant reduction infacial erythema compared to the vehicle group over a 12-hour period onday 28.

The pair-wise comparison showed no statistically significant differencesin response rates over a 12-hour time period on day 28 between any ofthe Oxy twice-daily or once-daily treatment groups. However, anumerically higher response rate was observed for the Oxy 1.00% QD groupversus the Oxy 0.5% QD group at hours 2, 4, 6, 8, and 10. The treatmentresponse rate on day 28 was similar between the Oxy 1.5% QD and Oxy 1.0%QD treatment groups. When comparing each dose following twice-daily oronce-daily dosing (ie, Oxy 1.5% BID versus Oxy 1.5% QD, Oxy 1.0% BIDversus Oxy 1.0% QD, and Oxy 0.5% BID versus Oxy 0.5% QD), response rateswere similar in each treatment group at each timepoint.

TABLE 5-1 Primary Efficacy Variable: Treatment Responder Rate of atLeast 2-grade Improvement on CEA and SSA from Baseline by TreatmentGroup, Visit and Timepoint (mITT Population) Twice-daily Dosing Oxy 1.5%BID Oxy 1.0% BID Oxy 0.5% BID Vehicle BID Day 14 Day 28 Timepoint Day 1% Day 14 % Day 28 % Day 1 % Day 14 % Day 28 % Day 1 % Day 14 % Day 28 %Day 1 % % % (Hour)^(a) (x/n) (x/n) (x/n) (x/n) (x/n) (x/n) (x/n) (x/n)(x/n) (x/n) (x/n) (x/n) 0.5  2.2  6.7  6.7  2.2  2.2  6.7 0.0 0.0  6.70.0 9.1 2.3 (1/45) (3/45) (3/45) (1/45) (1/45) (3/45) (0/45) (0/45)(3/45) (0/44) (4/44) (1/44) 1  2.2 11.1  8.9  8.9  6.7 11.1 0.0 0.0  6.74.5 4.5 2.3 (1/45) (5/45) (4/45) (4/45) (3/45) (5/45) (0/45) (0/45)(3/45) (2/44) (2/44) (1/44) 2 17.8 13.3 15.6 20.0 11.1 17.8 0.0 4.4  8.92.3 2.3 6.8 (8/45) (6/45) (7/45) (9/45) (5/45) (8/45) (0/45) (2/45)(4/45) (1/44) (1/44) (3/44) 4 17.8 13.3 22.2 17.8 22.2 20.0 11.1  6.711.1 0.0 2.3 6.8 (8/45) (6/45) (10/45)  (8/45) (10/45)  (9/45) (5/45)(3/45) (5/45) (0/44) (1/44) (3/44) 6 17.8  2.2 24.4 17.8 17.8 13.3 4.46.7 11.1 4.5 6.8 4.5 (8/45) (1/45) (11/45)  (8/45) (8/45) (6/45) (2/45)(3/45) (5/45) (2/44) (3/44) (2/44) 8 15.6 11.1 20.0 20.0 20.0 20.0 6.711.1   8.9 0.0 6.8 2.3 (7/45) (5/45) (9/45) (9/45) (9/45) (9/45) (3/45)(5/45) (4/45) (0/44) (3/44) (1/44) 10 24.4 15.6 26.7 13.3 17.8 15.611.1  13.3  13.3 0.0 4.5 2.3 (11/45)  (7/45) (12/45)  (6/45) (8/45)(7/45) (5/45) (6/45) (6/45) (0/44) (2/44) (1/44) 12  8.9 13.3 15.6 13.317.8 11.1 4.4 8.9 13.3 0.0 4.5 4.5 (4/45) (6/45) (7/45) (6/45) (8/45)(5/45) (2/45) (4/45) (6/45) (0/44) (2/44) (2/44) P-value^(b)  <0.001  0.121   0.006  <0.001   0.015   0.021  0.020   0.290   0.143Once-daily Dosing Oxy 1.5% QD Oxy 1.0% QD Oxy 0.5% QD Vehicle QD Day 14Day 28 Timepoint Day 1 % Day 14 % Day 28 % Day 1 % Day 14 % Day 28 % Day1 % Day 14 % Day 28 % Day 1 % % % (Hour)^(a) (x/n) (x/n) (x/n) (x/n)(x/n) (x/n) (x/n) (x/n) (x/n) (x/n) (x/n) (x/n) 0.5  0.0  4.5  6.8  0.0 2.3 11.4 0.0 2.2  6.7 0.0 2.3 4.5 (0/44) (2/44) (3/44) (0/44) (1/44)(5/44) (0/45) (1/45) (3/45) (0/44) (1/44) (2/44) 1  6.8 13.6 18.2  4.5 6.8 13.6 4.4 4.4 11.1 0.0 4.5 2.3 (3/44) (6/44) (8/44) (2/44) (3/44)(6/44) (2/45) (2/45) (5/45) (0/44) (2/44) (1/44) 2 22.7 18.2 22.7 11.413.6 20.5 11.1  11.1  13.3 0.0 6.8 6.8 (10/44)  (8/44) (10/44)  (5/44)(6/44) (9/44) (5/45) (5/45) (6/45) (0/44) (3/44) (3/44) 4 34.1 15.9 27.320.5 15.9 31.8 11.1  13.3  17.8 4.5 6.8 4.5 (15/44)  (7/44) (12/44) (9/44) (7/44) (14/44)  (5/45) (6/45) (8/45) (2/44) (3/44) (2/44) 6 22.718.2 13.6 18.2 15.9 22.7 8.9 8.9 17.8 4.5 4.5 4.5 (10/44)  (8/44) (6/44)(8/44) (7/44) (10/44)  (4/45) (4/45) (8/45) (2/44) (2/44) (2/44) 8 22.713.6 20.5 18.2 13.6 20.5 6.7 8.9 15.6 2.3 4.5 4.5 (10/44)  (6/44) (9/44)(8/44) (6/44) (9/44) (3/45) (4/45) (7/45) (1/44) (2/44) (2/44) 10 15.9 6.8 13.6 11.4  6.8 20.5 6.7 4.4 17.8 6.8 2.3 4.5 (7/44) (3/44) (6/44)(5/44) (3/44) (9/44) (3/45) (2/45) (8/45) (3/44) (1/44) (2/44) 12  4.5 6.8 13.6  2.3  4.5 13.6 11.1  6.7 13.3 2.3 6.8 2.3 (2/44) (3/44) (6/44)(1/44) (2/44) (6/44) (5/45) (3/45) (6/45) (1/44) (3/44) (1/44)P-value^(b)  <0.001   0.111   0.012   0.022   0.133  0.006  0.086  0.423  0.049 BID = twice-daily; CEA = Clinician's Erythema Assessment scale;mITT = modified intent-to-treat; Oxy = oxymetazoline hydrochloride; QD =once daily; SSA = Subject Self-Assessment of Erythema Note: Bold valuesindicate statistical significance versus vehicle for that timepoint withPearson's chi-square test. ^(a)The timepoint was based on eCRF vsit andtime. ^(b)P-value for between-treatment comparisons over a 12-hourperiod (including hours 2, 4, 6, 8, 10, and 12) were based on ageneralized linear model with a logit link function and exchangeablecovariance structure using generalized estimation equations. The modelincluded fixed effects of treatment group and timepoints. Thecomparisons were made for active versus vehicle on the same visit day.

TABLE 5-2 Primary Efficacy Endpoint: Treatment Responder Rate of atLeast 2-grade Improvement on CEA and SSA from Baseline Over 12 Hours onDay 28 (mITT Population) Twice-daily Dosing Timepoint Oxy 1.5% BID Oxy1.0% BID Oxy 0.5% BID Vehicle BID (Hour)^(a) Description (N = 45) (N =45) (N = 45) (N = 44) 2 Responder (n [%])  7 (15.6) 8 (17.8) 4 (8.9)  3(6.8) Difference^(b) 8.7 11.0 2.1 Difference, 90% CI −2.10, 19.57 −0.27, 22.19 −7.27, 11.41 P-value^(c) 0.315 0.116 >0.999 4 Responder (n[%]) 10 (22.2) 9 (20.0) 5 (11.1) 3 (6.8) Difference^(b) 15.4 13.2 4.3Difference, 90% CI 3.48, 27.33  1.59, 24.78 −5.60, 14.19 P-value^(c)0.040 0.069 0.714 6 Responder (n [%]) 11 (24.4) 6 (13.3) 5 (11.1) 2(4.5) Difference^(b) 19.9 8.8 6.6 Difference, 90% CI 8.20, 31.60 −0.99,18.56 −2.68, 15.82 P-value^(c) 0.008 0.266 0.434 8 Responder (n [%])  9(20.0) 9 (20.0) 4 (8.9)  1 (2.3) Difference^(b) 17.7 17.7 6.6Difference, 90% CI 7.28, 28.18  7.28, 28.18 −1.26, 14.49 P-value^(c)0.015 0.015 0.361 10 Responder (n [%]) 12 (26.7) 7 (15.6) 6 (13.3) 1(2.3) Difference^(b) 24.4 13.3 11.1 Difference, 90% CI 12.97, 35.82  3.69, 22.88  1.97, 20.15 P-value^(c) 0.001 0.058 0.110 12 Responder (n[%])  7 (15.6) 5 (11.1) 6 (13.3) 2 (4.5) Difference^(b) 11.0 6.6 8.8Difference, 90% CI 0.76, 21.26 −2.68, 15.82 −0.99, 18.56 P-value^(c)0.157 0.434 0.266 P-value^(d) 0.006 0.021 0.143 Once-daily DosingTimepoint Oxy 1.5% QD Oxy 1.0% QD Oxy 0.5% QD Vehicle QD (Hour)^(a)Description (N = 44) (N = 44) (N = 45) (N = 44) 2 Responder (n [%]) 10(22.7)  9 (20.5) 6 (13.3) 3 (6.8) Difference^(b) 15.9 13.6 6.5Difference, 90% CI 3.82, 28.00 1.88, 25.40 −3.87, 16.90  P-value^(c)0.035 0.062 0.485 4 Responder (n [%]) 12 (27.3)  14 (31.8)  8 (17.8) 2(4.5) Difference^(b) 22.7 27.3 13.2 Difference, 90% CI 10.57, 34.88 14.66, 39.89  2.56, 23.90 P-value^(c) 0.004 <0.001 0.090 6 Responder (n[%]) 6 (13.6) 10 (22.7)  8 (17.8) 2 (4.5) Difference^(b) 9.1 18.2 13.2Difference, 90% CI −0.83, 19.02  6.61, 29.75 2.56, 23.90 P-value^(c)0.266 0.013 0.090 8 Responder (n [%]) 9 (20.5) 9 (20.5) 7 (15.6) 2 (4.5)Difference^(b) 15.9 15.9 11.0 Difference, 90% CI 4.68, 27.13 4.68, 27.130.76, 21.26 P-value^(c) 0.024 0.024 0.157 10 Responder (n [%]) 6 (13.6)9 (20.5) 8 (17.8) 2 (4.5) Difference^(b) 9.1 15.9 13.2 Difference, 90%CI −0.83, 19.02  4.68, 27.13 2.56, 23.90 P-value^(c) 0.266 0.024 0.09012 Responder (n [%]) 6 (13.6) 6 (13.6) 6 (13.3) 1 (2.3) Difference^(b)11.4 11.4 11.1 Difference, 90% CI 2.11, 20.61 2.11, 20.61 1.97, 20.15P-value^(c) 0.110 0.110 0.110 P-value^(d) 0.012 0.006 0.049 BID = twicedaily; CEA = Clinician's Erythema Assessment; CI = confidence interval;mITT = modified intent-to-treat; Oxy = oxymetazoline hydrochloride; QD =once daily; SSA = Subject Self-Assessment of Erythema Note: A responderwas defined at least a 2-grade improvement from baseline on both CEA andSSA. The baseline value was the value collected on day 1 predose(baseline). If day 1 predose data were missing, screening visit datawere used. The last observation carried forward method was used formissing data at postbaseline visits. ^(a)The timepoint was based on eCRFvisit and time. ^(b)The treatment difference was calculated for activetreatment group minus its vehicle of the same dose regimen. ^(c)P-valuesfor between-treatment comparisons at a single timepoint were based on aPearson's chi-square test or Fisher's exact test. ^(d)P-values forbetween-treatment comparisons over a 12-hour period (ie, hours 2, 4, 6,8, 10, and 12) were based on a generalized linear model with a logitlink function and exchangeable convariance structure using generalizedestimation equations. The model included fixed effects of treatmentgroup and timepoints.Post Treatment Period

Additional post hoc analyses were conducted to evaluate the compositeendpoint during posttreatment period (days 29 to 56), as well as theproportion of patients with rebound/worsening of erythema on both CEAand SSA during posttreatment period. These analyses demonstrated thatthe proportions of patients with at least a 2-grade improvement frombaseline on both the CEA and SSA were greater than vehicle in the Oxy1.5%, 1.0%, and 0.5% twice-daily treatment groups at the majority oftimepoints during the post-treatment period. Treatment response wassimilar for all 3 Oxy once-daily groups compared with vehicle at alltimepoints. There were no statistically significant between-groupdifferences at any timepoint in the twice-daily and once-daily treatmentgroups.

No patients had rebound or worsening of erythema, as defined by a1-grade worsening on both the CEA and SSA scales from baseline duringthe posttreatment period.

5.1.2 Secondary Efficacy Analysis

The secondary efficacy variables were defined as the proportions ofpatients with at least a 2-grade decrease (improvement) on both CEA andSSA from baseline at hour 0.5 and hour 1.0 after application of thefirst dose on day 28.

The proportions of responders following twice-daily dosing at hour 0.5on day 28 were 6.7% for all 3 Oxy treatment groups compared to 2.3% withvehicle (Table 5-3). The proportions of responders following twice-dailydosing at hour 1.0 on day 28 were 8.9%, 11.1%, and 6.7% for Oxy 1.5%,1.0%, and 0.5%, respectively, compared to 2.3% with vehicle. There wereno statistically significant differences between the Oxy and vehicletreatment groups with twice-daily dosing at hours 0.5 and 1.0.

The proportions of responders following once-daily dosing at hour 0.5 onday 28 were 6.8%, 11.4%, and 6.7% for Oxy 1.5%, 1.0%, and 0.5%,respectively, compared to 4.5% with vehicle. The proportions ofresponders following once-daily dosing at hour 1.0 on day 28 were 18.2%,13.6%, and 11.1% for Oxy 1.5%, 1.0%, and 0.5%, respectively, compared to2.3% with vehicle. There was a statistically significant differencebetween the Oxy 1.5% QD and vehicle treatment groups with once-dailydosing at hour 1.0.

5.1.3 Other Efficacy Analyses

5.1.3.1 Other Analyses of Primary Efficacy Variable

At Least 1-Grade Improvement on Both CEA and SSA

The proportions of patients with at least a 1-grade decrease(improvement) from baseline over a 12-hour period for both the CEA andSSA were significantly greater than vehicle in the Oxy 1.5%, 1.0%, and0.5% BID treatment groups and the Oxy 1.5%, 1.0%, and 0.5% QD treatmentgroups on day 1, and in the Oxy 1.5% and 0.5% QD treatment groups on day14 (Table 5-4). Statistically significant differences compared withvehicle were seen starting at hour 2 on day 1 for all Oxy treatmentgroups.

On the day 28 primary timepoint, the proportions of patients with atleast a 1-grade improvement from baseline over a 12-hour period for boththe CEA and SSA were significantly greater than vehicle in the Oxy 1.5%,1.0%, and 0.5% QD treatment groups (Table 5-4). Statisticallysignificant between-group differences were seen starting at hour 2 onday 28 for the Oxy 1.5% and 1.0% QD groups, and at hour 4 in the Oxy0.5% QD group. There were few statistically significant between-groupdifferences following twice-daily dosing on day 28 at any timepoint.

TABLE 5-3 Number (%) of Patients with at Least 2-grade Improvement onCEA and SSA from Baseline at 0.5 Hour and 1 Hour Postdose on Day 28(mITT Population) Twice-daily Dosing Timepoint Oxy 1.5% BID Oxy 1.0% BIDOxy 0.5% BID Vehicle BID (Hour)^(a) Description (N = 45) (N = 45) (N =45) (N = 44) 0.5 Responder (n [%]) 3 (6.7) 3 (6.7)  3 (6.7) 1 (2.3)Difference^(b) 4.4 4.4 4.4 Difference, 90% CI −2.73, 11.52 −2.73, 11.52−2.73, 11.52 P-value^(c) 0.616 0.616 0.616 1 Responder (n [%]) 4 (8.9) 5(11.1) 3 (6.7) 1 (2.3) Difference^(b) 6.6 8.8 4.4 Difference, 90% CI−1.26, 14.49  0.32, 17.36 −2.73, 11.52 P-value^(c) 0.361 0.203 0.616Once-daily Dosing Timepoint Oxy 1.5% QD Oxy 1.0% QD Oxy 0.5% QD VehicleQD (Hour)^(a) Description (N = 44) (N = 44) (N = 45) (N = 44) 0.5Responder (n [%]) 3 (6.8) 5 (11.4) 3 (6.7) 2 (4.5) Difference^(b) 2.36.8 2.1 Difference, 90% CI −5.81, 10.36 −2.57, 16.20 −5.86, 10.10P-value^(c) >0.999 0.434 >0.999 1 Responder (n [%]) 8 (18.2) 6 (13.6)  5(11.1) 1 (2.3) Difference^(b) 15.9 11.4 8.8 Difference, 90% CI  5.69,26.13  2.11, 20.61  0.32, 17.36 P-value^(c) 0.030 0.110 0.203 BID =twice daily; CEA = Clinician's Erythema Assessment; CI = confidenceinterval; mITT = modified intent-to-treat; Oxy = oxymetazolinehydrochloride; QD = once daily; SSA = Subject Self-Assessment ofRrythema Note: The baseline value was the value collected on day 1predose (baseline). If day 1 predose data were missing, screening visitdata were used. The last observation carried forward method was used formissing data at postbaseline visits. ^(a)The timepoint was based on eCRFvisit and time. ^(b)The treatment difference was calculated for activetreatment group minus its vehicle of the same dose regimen. ^(c)P-valuesfor between-treatment comparisons at a single timepoint were based on aPearson's chi-square test or Fisher's exact test.

TABLE 5-4 Number (%) of Patients with at Least 1-grade Improvement onCEA and SSA from Baseline at 12 Hours Postdose on Days 1, 14, and 28(mITT Population) Twice-daily Dosing Timepoint Oxy 1.5% BID Oxy 1.0% BIDOxy 0.5% BID Vehicle BID (Hour)^(a) Description (N = 45) (N = 45) (N =45) (N = 44) Day 1 Responder (n [%]) 23 (51.1) 22 (48.9) 22 (48.9)  8(18.2) Hour 12 Difference^(b) 32.9 30.7 30.7 Difference, 90% CI 17.43,48.43 15.21, 46.21  15.21, 46.21 P-value^(c) 0.001 0.002 0.002P-value^(d) <0.001 <0.001 <0.001 Day 14 Responder (n [%]) 21 (46.7) 20(44.4) 19 (42.2) 19 (43.2) Hour 12 Difference^(b) 3.5 1.3 −1.0Difference, 90% CI −13.80, 20.77  −15.99, 18.51  −18.16, 16.24P-value^(c) 0.741 0.904 0.927 P-value^(d) 0.456 0.883 0.890 Day 28Responder (n [%]) 28 (62.2) 23 (51.1) 18 (40.0) 16 (36.4) Hour-12Difference^(b) 25.9 14.7 3.6 Difference, 90% CI  9.07, 42.65 −2.31,31.80 −13.24, 20.52 P-value^(c) 0.015 0.161 0.724 P-value^(d) 0.1060.197 0.529 Once-daily Dosing Timepoint Oxy 1.5% QD Oxy 1.0% QD Oxy 0.5%QD Vehicle QD (Hour)^(a) Description (N = 44) (N = 44) (N = 45) (N = 44)Day 1 Responder (n [%]) 19 (43.2) 21 (47.7) 18 (40.0)  9 (20.5) Hour 12Difference^(b) 22.7 27.3 19.5 Difference, 90% CI 6.93, 38.52 11.40,43.15  3.96, 35.13 P-value^(c) 0.022 0.007 0.045 P-value^(d) <0.001<0.001 0.001 Day 14 Responder (n [%]) 19 (43.2) 13 (29.5) 14 (31.1) 11(25.0) Hour 12 Difference^(b) 18.2 4.5 6.1 Difference, 90% CI 1.92,34.45 −11.01, 20.10  −9.47, 21.69 P-value^(c) 0.072 0.632 0.521P-value^(d) 0.002 0.081 0.035 Day 28 Responder (n [%]) 22 (50.0) 22(50.0) 17 (37.8) 10 (22.7) Hour 12 Difference^(b) 27.3 27.3 15.1Difference, 90% CI 11.14, 43.40  11.14, 43.40 −0.69, 30.79 P-value^(c)0.008 0.008 0.123 P-value^(d) 0.001 0.005 0.021 BID = twice daily; CEA =Clinician's Erythema Assessment; CI = confidence interval; mITT =modified intent-to-treat; Oxy = oxymetazoline hydrochloride; QD = oncedaily; SSA = Subject Self-Assessment of Erythema Note: The baselinevalue was the value collected on day 1 predose (baseline). If day 1predose data were missing, screening visit data were used. The lastobservation carried forward method was used for missing data atpostbaseline visits. ^(a)The timepoint was based on eCRF visit and time.^(b)The treatment difference was calculated for active treatment groupminus its vehicle of the same dose regimen. ^(c)P-values forbetween-treatment comparisons at a single timepoint were based on aPearson's chi-square test or Fisher's exact test. ^(d)P-values forbetween-treatment comparisons over a 12-hour period (ie, hours 2, 4, 6,8, 10, and 12) were based on a generalized linear model with a logitlink function and exchangeable convariance structure using generalizedestimation equations. The model included fixed effects of treatmentgroup and timepoints.5.1.3.2 Clinician Erythema Assessment

Summary statistics of baseline and change from baseline on days 1, 14,28, 29, 35, and 56/exit for the CEA were taken. Frequency distributionsof CEA raw scores at screening and days 1, 14, 28, 29, 35, and 56/exitwere calculated, and summary statistics of CEA raw scores were done.

At Least 1-Grade Improvement

The proportions of patients with at least a 1-grade decrease(improvement) from baseline over a 12-hour period for the CEA weresignificantly greater than vehicle for all Oxy treatment groups on day1, for the Oxy 1.0% QD treatment group on day 14, and for the Oxy 1.5%,1.0%, and 0.5% QD treatment groups on day 28. Statistically significantdifferences compared with vehicle were seen starting at hour 2 on day 1for all Oxy treatment groups.

At Least 2-Grade Improvement

The proportions of patients with at least a 2-grade decrease(improvement) from baseline over a 12-hour period for the CEA weresignificantly greater than vehicle for all Oxy treatment groups on day1, for none of the Oxy treatment groups on day 14, and for the Oxy 1.0%and 0.5% QD treatment groups on day 28. Statistically significantdifferences compared with vehicle were seen starting at hour 2 or 4 onday 1 for all Oxy treatment groups.

5.1.3.3 Subject Self-Assessment of Erythema

Summary statistics of baseline and change from baseline on days 1, 14,28, 29, 35, and 56/exit for the SSA were conducted. Frequencydistributions of SSA raw scores at screening and days 1, 14, 28, 29, 35,and 56/exit were calculated and summary statistics of SSA raw scoreswere carried out.

At Least 1-Grade Improvement

The proportions of patients with at least a 1-grade decrease(improvement) from baseline over a 12-hour period for the SSA weresignificantly greater than vehicle for all Oxy twice-daily treatmentgroups and the Oxy 1.5% and 0.5% QD treatment groups on day 1, for theOxy 1.5% and 0.5% QD treatment groups on day 14, and for the Oxy 1.5%,1.0%, and 0.5% QD treatment groups on day 28. Statistically significantdifferences compared with vehicle were seen starting at hour 2 on day 1for a majority of the Oxy treatment groups.

At Least 2-Grade Improvement

The proportions of patients with at least a 2-grade decrease(improvement) from baseline over a 12-hour period for the SSA weresignificantly greater than vehicle for a majority of the Oxy twice-dailyand once-daily treatment groups on day 1, for a few of the Oxy treatmentgroups on day 14, and for the Oxy 1.5%, 1.0% and 0.5% QD treatmentgroups on day 28. Statistically significant differences compared withvehicle were seen starting at hour 2 on day 1 for all of the Oxyonce-daily treatment groups (Table 5-5).

TABLE 5-5 Number (%) of Patients with at Least 2-grade Improvement onSSA from Baseline at 12 Hours Postdose on Days 1, 14 and 28 (mITTPopulation) Twice-daily Dosing Timepoint Oxy 1.5% BID Oxy 1.0% BID Oxy0.5% BID Vehicle BID (Hour)^(a) Description (N = 45) (N = 45) (N = 45)(N = 44) Day 1 Responder (n [%]) 16 (35.6) 14 (31.1) 7 (15.6) 5 (11.4)Hour 12 Difference^(b) 24.2 19.7 4.2 Difference, 90% CI 10.10, 38.28 5.98, 33.52 −7.64, 16.03 P-value^(c) 0.007 0.023 0.563 P-value^(d)0.012 0.015 0.723 Day 14 Responder (n [%]) 11 (24.4) 18 (40.0) 11 (24.4)6 (13.6) Hour 12 Difference^(b) 10.8 26.4 10.8 Difference, 90% CI −2.70,24.31 11.69, 41.04 −2.70, 24.31 P-value^(c) 0.195 0.005 0.195P-value^(d) 0.356 0.011 0.821 Day 28 Responder (n [%]) 19 (42.2) 18(40.0) 12 (26.7) 10 (22.7)  Hour 12 Difference^(b) 19.5 17.3 3.9Difference, 90% CI  3.58, 35.41  1.44, 33.11 −11.04, 18.91  P-value^(c)0.050 0.079 0.667 P-value^(d) 0.057 0.056 0.751 Once-daily Dosing Oxy1.5% QD Oxy 1.0% QD Oxy 0.5% OD Vehicle QD Timepoint^(a) Description (N= 44) (N = 44) (N = 45) (N = 44) Day 1 Responder (n [%]) 13 (29.5)  9(20.5) 12 (26.7) 3 (6.8)  Hour 12 Difference^(b) 22.7 13.6 19.8Difference, 90% CI  9.84, 35.61  1.88, 25.40  7.37, 32.33 P-value^(c)0.006 0.062 0.012 P-value^(d) <0.001 0.003 0.001 Day 14 Responder (n[%]) 14 (31.8)  8 (18.2)  7 (15.6) 6 (13.6) Hour 12 Difference^(b) 18.24.5 1.9 Difference, 90% CI  3.88, 32.49 −8.22, 17.31 −10.35, 14.19 P-value^(c) 0.042 0.560 0.798 P-value^(d) <0.001 0.025 0.143 Day 28Responder (n [%]) 15 (34.1) 13 (29.5) 11 (24.4) 5 (11.4) Hour 12Difference^(b) 22.7 18.2 13.1 Difference, 90% CI  8.62, 36.83  4.44,31.92 −0.03, 26.19 P-value^(c) 0.011 0.034 0.108 P-value^(d) <0.0010.004 0.009 BID = twice daily; CI = confidence interval; mITT = modifiedintent-to-treat; Oxy = oxymetazoline hydrochloride; QD = once daily; SSA= Subject Self-Assessment of Erythema Note: The baseline value was thevalue collected on day 1 predose (baseline). If day 1 predose data weremissing, screening visit data were used. The last observation carriedforward method was used for missing data at postbaseline visits. ^(a)Thetimepoint was based on eCRF visit and time. ^(b)The treatment differencewas calculated for active treatment group minus its vehicle of the samedose regimen. ^(c)P-values for between-treatment comparisons at a singletimepoint were based on a Pearson's chi-square test or Fisher's exacttest. ^(d)P-values for between-treatment comparisons over a 12-hourperiod (ie, hours 2, 4, 6, 8, 10, and 12) were based on a generalizedlinear model with a logit link function and exchangeable convariancestructure using generalized estimation equations. The model includedfixed effects of treatment group and timepoints.5.1.3.4 Subgroup Analyses of Primary Efficacy Variable

The primary efficacy variable (ie, the proportion of patients with atleast a 2-grade improvement from baseline over a 12-hour period on day28 for both the CEA and SSA) was analyzed by age group (<45, 45 to 64,and ≥65 years of age), sex (male versus female), CEA score at baseline(3 versus 4), and SSA score at baseline (3 versus 4) to compare eachoxymetazoline treatment group to its vehicle.

Due to the small numbers of patients in the subgroup of males, patientsaged <45 and ≥65 years, and patients with CEA or SSA scores of 4,between-treatment comparisons are not reliable due to the limited samplesize.

In the subgroup of patients aged 45 to 64, female patients, and patientswith a CEA or SSA score of 3, a statistically significant reduction infacial erythema was demonstrated over a 12-hour period on day 28 for amajority of the Oxy twice-daily and once-daily treatment groups comparedto the vehicle groups.

In the subgroups of patients aged <45 and ≥65 years, male patients, andpatients with CEA or SSA score of 4, there were no statisticallysignificant between-group differences for any of the Oxy treatmentgroups versus vehicle.

Additional subgroup analyses were conducted to evaluate the proportionof patients with at least a 2-grade improvement from baseline over a12-hour period on day 28 for the CEA by CEA score at baseline (3 versus4), and the proportion of patients with at least a 2-grade improvementfrom baseline over a 12-hour period on day 28 for the SSA by SSA scoreat baseline (3 versus 4) to compare each oxymetazoline treatment groupto its vehicle.

In the subgroup of patients with CEA score of 3, the proportion ofpatients with at least a 2-grade improvement from baseline for the CEAwas significantly greater in the Oxy 1.0% QD treatment group compared tothe vehicle groups. In the subgroup of patients with SSA score of 3, theproportion of patients with at least a 2-grade improvement from baselinefor the SSA was significantly greater in the Oxy 1.5% BID and Oxy 1.0%BID treatment groups and all 3 Oxy once-daily treatment groups comparedto the vehicle groups.

In the subgroups of patients with CEA or SSA scores of 4, there were nostatistically significant between-group differences for any of the Oxytreatment groups versus vehicle possibly due to the limited sample sizein each treatment group.

Other Measures Analyses

5.1.4 Subject Self-Assessment of Rosacea Facial Redness

5.1.4.1 at Least 1-Grade Improvement on Both CEA and SSA-2

The proportions of patients with at least a 1-grade decrease(improvement) from baseline over a 12-hour period for both the CEA andSSA-2 were significantly greater than vehicle in all Oxy treatmentgroups on day 1 and for the Oxy 1.5% and 1.0% QD treatment groups on day14. Statistically significant differences compared with vehicle wereseen starting at hour 2 on day 1 for all Oxy treatment groups.

On day 28, the proportions of patients with at least a 1-gradeimprovement from baseline over a 12-hour period for both the CEA andSSA-2 were significantly greater than vehicle in the Oxy 1.5%, 1.0%, and0.5% QD treatment groups and the Oxy 1.0% BID group. Statisticallysignificant differences compared with vehicle were seen starting at hour2 on day 28 for the Oxy 1.5% and 1.0% QD groups. There were fewstatistically significant between-group differences followingtwice-daily dosing on day 28 at any timepoint.

5.1.4.2 at Least 2-Grade Improvement on Both CEA and SSA-2

On day 1, the proportions of patients with at least a 2-grade decrease(improvement) from baseline over a 12-hour period for both the CEA andSSA-2 were significantly greater than vehicle in the Oxy 1.5%, 1.0%, and0.5% BID treatment groups and the Oxy 1.5% and 1.0% QD treatment groups,with statistically significant differences starting at hour 2 or 4 forthese Oxy treatment groups compared with vehicle.

On day 14, the proportions of patients with at least a 2-gradeimprovement from baseline for both the CEA and SSA-2 were significantlygreater than vehicle in the Oxy 1.0% BID treatment group only, withstatistically significant differences compared with vehicle starting athour 4.

On day 28 in the mITT population, a statistically significant reductionin rosacea facial redness was demonstrated in the Oxy 1.5% and 1.0% BIDtreatment groups and the Oxy 1.5% and 1.0% QD treatment groups comparedwith vehicle. Statistically significant differences compared withvehicle were seen starting at hour 4 for the Oxy 1.5% and 1.0% BIDtreatment groups, and at hour 1 or 2 for the Oxy 1.5% and 1.0% QDtreatment groups. Similar results were observed in the PP population,whereby Oxy 1.5% and 1.0% given twice-daily or once-daily demonstrated astatistically significant reduction in rosacea facial redness comparedto vehicle over a 12-hour period on day 28.

TABLE 5-6 Number (%) of Patients with at Least 2-grade Improvement onCEA and SSA-2 from Baseline at 12 Hours Postdose on Days 1, 14, and 28(mITT Population) Twice-daily Dosing Oxy 1.5% BID Oxy 1.0% BID Oxy 0.5%BID Vehicle BID Timepoint^(a) Description (N = 45) (N = 45) (N = 45) (N= 44) Day 1 Responder (n [%]) 4 (8.9)  6 (11.1) 2 (4.4) 0 (0.0) Hour 12Difference^(b) 8.9 11.1 4.4 Difference, 90% CI  1.93, 15.85 3.43, 8.79−0.59, 9.48  P-value^(c) 0.117 0.056 0.494 P-value^(d) <0.001 0.0040.027 Day 14 Responder (n [%]) 5 (11.1) 7 (15.6) 3 (6.7)  1 (2.3) Hour12 Difference^(b) 8.8 13.3 4.4 Difference, 90% CI  0.32, 17.36  3.69,22.88 −2.73, 11.52 P-value^(c) 0.203 0.058 0.616 P-value^(d) 0.115 0.0090.244 Day 28 Responder (n [%]) 7 (15.6) 4 (8.9)  4 (8.9)  2 (4.5) Hour12 Difference^(b) 11.0 4.3 4.3 Difference, 90% CI  0.76, 21.26 −4.31,13.00 −4.31, 13.00 P-value^(c) 0.157 0.677 0.677 P-value^(d) 0.018 0.0190.400 Once-daily Dosing Oxy 1.5% QD Oxy 1.0% QD Oxy 0.5% QD Vehicle QDTimepoint^(a) Description (N = 44) (N = 44) (N = 45) (N = 44) Day 1Responder (n [%]) 2 (4.5)  2 (4.5)  4 (8.9)  0 (0.0) Hour 12Difference^(b) 2.3 4.5 8.9 Difference, 90% CI −4.06, 8.61  −−0.60, 9.70  1.93, 15.85 P-value^(c) >0.999 0.494 0.117 P-value^(d) <0.001 0.0230.175 Day 14 Responder (n [%]) 3 (6.8)  2 (4.5)  2 (4.4)  2 (4.5) Hour12 Difference^(b) 2.3 0.0 −0.1 Difference, 90% CI −5.81, 10.36 −7.28,7.28  −7.31, 7.10  P-value^(c) >0.999 >0.999 >0.999 P-value^(d) 0.1610.214 0.823 Day 28 Responder (n [%]) 6 (13.6) 5 (11.4) 5 (11.1) 1 (2.3)Hour 12 Difference^(b) 11.4 9.1 8.8 Difference, 90% CI  2.11, 20.61 0.42, 17.76  0.32, 17.36 P-value^(c) 0.110 0.202 0.203 P-value^(d)0.017 0.013 0.097 BID = twice daily; CEA = Clinician's ErythemaAssessment; CI = confidence interval; mITT = modified intent-to-treat;Oxy = oxymetazoline hydrochloride; QD = once daily; SSA-2 = SubjectSelf-Assessment of Rosacea Facial Redness Note: A responder was definedat least a 2-grade improvement from baseline on both CEA and SSA-2. Thebaseline value was the value collected on day 1 predose (baseline). Ifday 1 predose data were missing, screening visit data were used. Thelast observation carried forward method was used for missing data atpostbaseline visits. ^(a)The timepoint was based on eCRF visit and time.^(b)The treatment difference was calculated for active treatment groupminus its vehicle of the same dose regimen. ^(c)P-values forbetween-treatment comparisons at a single timepoint were based on aPearson's chi-square test or Fisher's exact test. ^(d)P-values forbetween-treatment comparisons over a 12-hour period (ie, hours 2, 4, 6,8, 10, and 12) were based on a generalized linear model with a logitlink function and exchangeable convariance structure using generalizedestimation equations. The model included fixed effects of treatmentgroup and timepoints.5.1.4.3 Posttreatment Period

During the posttreatment period, there were no statistically significantbetween-group differences at any timepoint in the twice-daily andonce-daily treatment groups compared with the vehicle groups for theproportions of patients with at least a 2-grade improvement frombaseline on both the CEA and SSA-2.

No patients had rebound or worsening of rosacea facial redness, asdefined by a 1-grade worsening on both the CEA and SSA-2 scales frombaseline during the posttreatment period.

5.1.4.4 SSA-2 by Treatment Group

Summary statistics of baseline and change from baseline on days 1, 14,28, 29, 35, and 56/exit for the SSA-2 were taken. Frequencydistributions of SSA-2 raw scores at screening and days 1, 14, 28, 29,35, and 56/exit were carried out, and summary statistics of SSA-2 rawscores were carried out.

At Least 1-Grade Improvement

The proportions of patients with at least a 1-grade decrease(improvement) from baseline over a 12-hour period for the SSA-2 weresignificantly greater than vehicle for all Oxy twice-daily andonce-daily treatment groups on day 1, for the Oxy 1.5% and 0.5% QDtreatment groups on day 14, and for the Oxy 1.5%, 1.0%, and 0.5% QDtreatment groups on day 28. Statistically significant differencescompared with vehicle were seen starting at hour 2 on day 1 for all Oxytreatment groups.

At Least 2-Grade Improvement

The proportions of patients with at least a 2-grade decrease(improvement) from baseline over a 12-hour period for the SSA weresignificantly greater than vehicle for the Oxy 1.5% BID and Oxy 1.5%,1.0%, and 0.5% QD treatment groups on day 1, for the Oxy 1.0% BID, Oxy1.5% QD, and Oxy 1.0% QD treatment groups on day 14, and for the Oxy1.5%, 1.0% and 0.5% QD treatment groups on day 28. Statisticallysignificant differences compared with vehicle were seen starting at hour2 on day 1 for all of the Oxy QD treatment groups and the Oxy 1.0% BIDtreatment group.

5.1.4.5 Subgroup Analyses of SSA-2

The proportions of patients with at least a 2-grade improvement frombaseline over a 12-hour period on day 28 for both the CEA and SSA-2, aswell for the SSA-2 alone, were analyzed by SSA-2 score at baseline (3versus 4) to compare each oxymetazoline treatment group to its vehicle.

In the subgroup of patients with SSA-2 score of 3 at baseline, theproportion of patients with at least a 2-grade improvement from baselinefor both the CEA and SSA-2 was significantly greater in the Oxy 1.5% and1.0% BID and all 3 Oxy once-daily treatment groups compared to thevehicle groups. In this subgroup, the proportion of patients with atleast a 2-grade improvement from baseline for the SSA-2 alone wassignificantly greater in all 3 Oxy once-daily treatment groups comparedto the vehicle groups, but not for the Oxy twice-daily treatment groups.

In the subgroups of patients with SSA-2 score of 4 at baseline, therewere no statistically significant between-group differences for any ofthe Oxy treatment groups versus vehicle.

5.1.5 Correlation Analyses

The correlation analyses included raw data and change from baseline databetween the CEA and SSA, the CEA and SSA-2, and the SSA and SSA-2. Theseanalyses demonstrated that there was a high correlation between the SSAand SSA-2 with a Spearman correlation coefficient of 0.85 (90% CI[0.842, 0.851]). The correlations between the CEA and SSA and betweenthe CEA and SSA-2 were similar, with Spearman correlation coefficientsof 0.40 (90% CI [0.390, 0.416]) and 0.43 (90% CI [0.420, 0.446]),respectively.

5.1.6 Aesthetic Questionnaire

The AQ was administered to patients on days 14 and 28 and assessedpatient's facial skin type, other medication used to treat rosacea, easeof application, smell, speed of drying, greasiness/stickiness,moisturizing effect, glossy/shiny appearance, residue, and any effect oftreatment on routine application of makeup or sunscreen.

The largest proportion of patients in all treatment groups hadcombination skin.

Other medications used to treat rosacea were taken into consideration.

The largest proportion of patients in all treatment groups stated thatit took more than 15 minutes for the study medication to dry, but thatit was not bothersome to wait for the study medication to dry. Amajority of all patients (48.3%) preferred a cream product rather thanother types of products that were not used in this study, ie, lotion(18.5%), pad (8.7%), gel (7.9%), spray/mist (6.7%), foam (2.8%), andointment (2.2%).

On days 14 and 28, the largest proportion of patients in all treatmentgroups stated that the study medication was easy to apply, wasfragrance-free, was absorbed and dried quickly, was not greasy orsticky, was moisturizing/hydrating, did not interfere with their facialmake-up routine, moisturizer or sunscreen application, and did not leavea residue on their face after it dried.

5.1.7 Digital Image Analyses

The results of the exploratory DIA data (for once-daily dosing only)were analyzed by Canfield Scientific, Inc.

In summary, among the 6 measures evaluated from the DIA (ie, FractionalArea, Erythema Severity, Erythema Redness, Erythema Contrast, Intensityof Erythema, and Erythema Visibility), Fractional Area had the bestcorrelation with the CEA scale, with a Spearman correlation coefficientof 0.47 (95% CI [0.436, 0.498]. In general, there was a gooddifferentiation on the improvement from baseline in Fractional Areabetween the Oxy once-daily groups and the vehicle once-daily group.

5.2 Health Outcomes Analyses

A summary of the proportion of patients with at least a 1-gradeimprovement on each question of the PRO measures from baseline on day 28is provided below. Note that all PRO measures were administered atpredose for validation purposes, which may have resulted in lowerscores.

5.2.1 Symptom Assessment for Rosacea Facial Redness

Patients were asked to assess their symptoms in the present moment(“right now”) on visit days 1, 14, and 28. At the day 28 assessment, theproportions of patients with at least a 1-grade improvement on eachquestion of the Symptom Assessment were similar for all treatment arms.The proportions ranged from 35.6% to 68.9%, for the active treatmentgroups compared to 31.8% to 72.7% for the vehicle groups.

On day 28, the mean changes from baseline in the score for most SymptomAssessment questions were not significantly different for the treatmentgroups.

The frequency distributions of responses for each Symptom Assessmentquestion are shown by treatment group and visit. These frequencydistributions were generally similar for the treatment groups regardlessof the dosing regimen.

The results of the treatment group are not substantially different fromthe vehicle groups because the PRO was administered predose.

5.2.2 Impact Assessment for Rosacea Facial Redness

Patients were asked to assess the impacts related to erythema associatedrosacea over the past 7 days on visit days 1, 14, and 28. Theproportions of patients with at least a 1-grade improvement at the day28 assessment on each question of the Impact Assessment were similar forall treatment arms. The proportions ranged from 21.4% to 77.8% for theactive treatment groups compared to 23.3% to 77.3% for the vehiclegroups.

On day 28, the mean changes from baseline in the score for most ImpactAssessment questions were not significantly different for the treatmentgroups.

The frequency distributions of responses for each Impact Assessmentquestion are shown by treatment group and visit. These frequencydistributions were generally similar for all the treatment groupsregardless of the dosing regimen.

The similarity in the results between the treatment and vehicle groupsmay be due to the fact that oxymetazoline has a transient effect onerythema. Although the recall period was 7 days, the variable nature ofthe condition may have impacted patients' responses.

5.2.3 Satisfaction Assessment for Rosacea Facial Redness

Patients were asked to assess their satisfaction in the present moment(“right now”) on visit days 1, 14, and 28. At the day 28 assessment, theproportions of patients with at least a 1 grade improvement on eachquestion of the Satisfaction Assessment were similar for all treatmentarms. The reported proportions were up to 43.2% for the active treatmentgroups and up to 45.2% for the vehicle groups respectively.

On day 28, the mean changes from baseline in the score for eachSatisfaction Assessment question were not significantly different forthe treatment groups.

The frequency distribution of responses for each Satisfaction Assessmentquestion by treatment group were similar at each follow up visit.

The results of the treatment group are not substantially different fromthe vehicle groups because the PRO was administered predose.

5.3 Pharmacokinetic Results

5.3.1 Anomalous Concentration Values

The following patients had timepoints that were considered as outliervalues according to SOP DSEPK-001: 1100 (day 14, 12 hour), 1138 (day 28,2 hour), 1180 (day 1, 8 hour), 1188 (day 28, 8 hour), 1222 (day 28, 8hour), 1236 (day 1, 2 hour), 1247 (day 14, predose), 1281 (day 1, alltimepoints), 1274 (day 1, 4, and 8 hours), 1286 (day 1, all timepointsand day 28, 12 hour), 1289 (day 1, all timepoints), 1316 (day 28, alltimepoints), 1349 (day 1, all timepoints), 1350 (day 1, 12 hour), and1458 (day 28, predose). In addition, the following patients hadmeasurable predose values on day 1 which were excluded from theanalysis: 1155, 1097, 1283, 1316, 1356, and 1249. Pharmacokineticparameters for these patients were calculated without these outliervalues.

5.3.2 Missing Patient Data

A total of 238 samples from 36 patients on active treatment were notincluded in the data analysis. These included 0.11%, 3.64%, and 4.89% ofsamples from the Oxy 1.5%, 1.0%, and 0.5% QD groups, respectively, and6.33%, 7.00%, and 4.56% of samples from the Oxy 1.5%, 1.0%, and 0.5% BIDgroups, respectively.

-   -   138 samples from 24 patients were not collected due to a missed        visit or difficulties in drawing blood    -   86 samples from 7 patients were not collected due to early exit        from the study    -   9 samples from 4 patients were collected, however, were not able        to be located at the time of analysis, therefore, were        considered missing    -   1 sample from 1 patient was not able to be analyzed due to        insufficient volume    -   4 samples from 2 patients were analyzed, however, their data was        not reportable due to re-assay failure

No adjustment or imputation was utilized for missing values. Missingsamples did not impact the overall objective of the study.

Pharmacokinetic Evaluation

Pharmacokinetic parameters, where applicable, were calculated for eachpatient following dermal administration of oxymetazoline cream and aresummarized in Table 5-7. The maximum concentrations in the once-dailyand twice-daily dose groups were observed between 6 to 12 hours (medianT_(max)) and 4 to 6 hours (median T_(max)) postdose, respectively. Ashort T_(max) for the twice-daily dosing regimens was observed becausethe second dose on each day was administered 6 hours after the firstdose, and the first dose on the next day was administered 18 hours afterthe second dose on the previous day. Following once-daily dosing, themean C_(max) in the 1.5% dose group on day 28 was 98.0 pg/mL which wassimilar to the 115 pg/mL mean C_(max) observed in the Oxy 1.5% BIDtreatment group on day 28. The highest mean AUC₀₋₂₄ followingadministration of 1.5% once-daily or BID was 1680 and 2660 pg·hr/mL,respectively. With an increase in dosing frequency (twice-daily), theredid not appear to be an equal increase in systemic exposure whencompared to once-daily dosing. Across all treatment groups, the meanC_(max) and AUC₀₋₂₄ were generally lower than that observed following asingle administration of Afrin® nasal spray (0.05% oxymetazoline), wherethe mean C_(max) was 245 pg/mL and the mean AUC₀₋₁₂ was 1741 pg·hr/mL(oxymetazoline clinical study). A plot of the trough concentrationsindicates that steady state may have been reached by the second dose forthe once-daily groups and after the third dose for the twice-dailygroups. Steady state systemic exposure to oxymetazoline appeared toincrease approximately dose proportionally following once-daily ortwice-daily dermal administration of 0.5%, 1.0%, and 1.5% oxymetazolinecream. Following 28 days of dosing, a mean accumulation ratio ofapproximately 2 was observed across all once-daily treatment groups.Increased accumulation was observed in the twice-daily treatment groups,with a mean accumulation ratio between 4.86 and 6.48 when comparing AUCafter the first dose on days 1 and 28. A prolonged effective half-lifewas observed following dermal administration of oxymetazoline cream(mean 18-28 hours) when compared to the terminal half-life for Afrin®nasal spray (mean 5 hours, oxymetazoline clinical study), probablyattributable to the different routes of administration.

TABLE 5-7 Mean Pharmacokinetic Parameters Following DermalAdministration of Oxymetazoline Cream to Patients with ErythemaAssociated with Rosacea Treatment T_(max) C_(max) AUC₀₋₂₄ ^(a) AUC₀₋₆^(b) T_(eff) ^(d) Group Day (hr) (pg/mL) (pg · hr/mL) (pg · hr/mL) R₀^(c) (hr) Oxy 0.5% 1 12 (4, 24) 35.0 ± 56.7 467 ± 558 NA 2.13 ± 0.8225.9 ± 14.2 QD 28  6 (0, 24) 41.5 ± 30.0 590 ± 518 NA Oxy 1.0% 1 12 (2,24) 60.5 ± 53.9 895 ± 798 NA 1.75 ± 0.83 18.8 ± 14.9 QD 28 10 (0, 24)66.4 ± 67.1 1050 ± 992  NA Oxy 1.5% 1 10 (4, 24) 68.5 ± 54.6 1090 ± 794 NA 2.26 ± 1.42 28.0 ± 24.3 QD 28  8 (0, 24) 98.0 ± 79.5 1680 ± 1430 NAOxy 0.5% 1 6 (2, 6) 20.6 ± 11.1 563 ± 357 49.9 ± 40.8 4.99 ± 5.18 18.5 ±21.6 BID 28 6 (0, 6) 39.0 ± 29.7 752 ± 581 168 ± 129 Oxy 1.0% 1 6 (4, 6)56.9 ± 68.9 1400 ± 1220 155 ± 154 6.48 ± 6.05 24.7 ± 25.3 BID 28 4 (0,6) 68.8 ± 61.1 1530 ± 922  311 ± 252 Oxy 1.5% 1 6 (4, 6) 62.6 ± 65.71740 ± 942  183 ± 152 4.86 ± 3.45 18.0 ± 14.4 BID 28 6 (0, 6) 115 ± 1112660 ± 2170 563 ± 609 C_(max) = maximum observed plasma concentration;BID = twice daily, NA = not available, QD = once daily; T_(max) = timecorresponding to maximum observed plasma concentration Note, all datawere reported as mean ± standard deviation, except for T_(max) which wasreported as median (min, max). ^(a)AUC₀₋₂₄ for twice-daily groupscalculated as the sum of AUC₀₋₆ and AUC₆₋₂₄ ^(b)AUC₀₋₆ calculated fortwice-daily groups only; represents AUC after morning dose on day 1 andday 28 ^(c)R₀ = accumulation ratio = AUC_(Day 28)/AUC_(Day 1)^(d)T_(eff) = effective half-life = (τ × ln0.5)/ln(1 − 1/R₀) Source:Table 16.1.13.1-15.4 Efficacy Conclusions

-   -   A statistically significant reduction in facial erythema as        measured by the composite assessment, ie, the proportions of        patients with at least a 2-grade decrease (improvement) from        baseline over a 12-hour period for both the CEA and SSA on day        28, was demonstrated with the 1.5% and 1.0% doses of        oxymetazoline cream following twice-daily dosing (p=0.006 and        p=0.021, respectively), and with all 3 doses of oxymetazoline        cream (1.5° 0%, 1.0%, and 0.5%) following once-daily dosing        (p=0.012, p=0.006, and p=0.049, respectively).    -   The proportions of responders in the twice-daily treatment        groups at hour 4 (peak timepoint) on day 28 were 22.2%, 20.0%        and 11.1% with Oxy 1.5%, 1.0%, and 0.5%, respectively, compared        to 6.8% with vehicle. The proportions of responders in the        twice-daily treatment groups were maintained at hour 12 on day        28, with 15.6%, 11.1% and 13.3% in the Oxy 1.5%, 1.0%, and 0.5%        groups, respectively, compared to only 4.5% in the vehicle        group.    -   The proportions of responders in the once-daily treatment groups        at hour 4 (peak timepoint) on day 28 were 27.3%, 31.8% and 17.8%        with Oxy 1.5%, 1.0%, and 0.5%, respectively, compared to 4.5%        with vehicle. The proportions of responders in the once-daily        treatment groups were maintained at hour 12 on day 28, with        13.6%, 13.6%, and 13.3% in the Oxy 1.5%, 1.0%, and 0.5% groups,        respectively, compared to only 2.3% in the vehicle group.    -   A statistically significant difference based on the composite        2-grade improvement was observed as early as 2 hours after the        first application on day 1 for a majority of the Oxy treatment        groups compared with vehicle.    -   The pair-wise comparison showed no statistically significant        differences in response rates over a 12-hour time period on day        28 between any of the Oxy twice-daily or once-daily treatment        groups, demonstrating that twice-daily dosing did not provide        any significant improvement over once-daily dosing for any of        the Oxy treatment groups. A numerically higher response rate was        observed for Oxy 1.0% QD versus Oxy 0.5% QD at most timepoints.        When comparing the Oxy 1.5% QD and the 1.0% QD doses, the        response rates were similar.    -   For the secondary efficacy variables (defined as the proportions        of patients with at least a 2-grade improvement on both the CEA        and SSA from baseline at hour 0.5 and hour 1.0 after application        of the first dose on day 28), only the Oxy 1.5% QD treatment        group showed statistically significant differences compared with        vehicle at hour 1.0.    -   The response rates on day 28 were higher compared with response        rates on day 1 for all Oxy treatment groups, demonstrating that        no tachyphylaxis was observed during the study.    -   A statistically significant reduction in rosacea facial redness,        as demonstrated by the proportions of patients with at least a        2-grade decrease (improvement) from baseline over a 12-hour        period for both the CEA and SSA-2, was observed with Oxy 1.5%        and 1.0% given twice-daily and once-daily compared with vehicle        on day 28, with responses observed as early as day 1.    -   Correlation analyses demonstrated that there was a high        correlation between the SSA and SSA-2 with a Spearman        correlation coefficient of 0.85 (90% CI [0.842, 0.851]).    -   There were no statistically significant between-group        differences in the proportions of responders at any timepoint        during the 4-week posttreatment period. During this follow-up        phase, During this follow-up phase, no patients had rebound or        worsening of erythema, as defined by a 1-grade worsening from        baseline on both of the CEA and SSA scales, as well as both of        the CEA and SSA-2 scales.    -   Subgroup analyses of the primary efficacy variable demonstrated        that treatment with oxymetazoline was efficacious in the        reduction of erythema regardless of sex, age, CEA score at        baseline, or SSA score at baseline.        6. Safety Evaluation        6.1 Extent of Exposure

A total of 357 patients were enrolled into the study, of which 356patients received at least 1 dose of study medication and were includedin the safety population. One patient was randomized by error; thispatient did not receive study treatment and was not included in thesafety population. A total of 179 patients received twice-dailytreatment (135 Total Oxy and 44 vehicle), and 177 patients receivedonce-daily treatment (133 Total Oxy and 44 vehicle).

The mean total study duration was 55.1 days and the mean total treatmentduration was 27.8 days. Mean exposure times were similar across alltreatment groups.

6.2 Adverse Events

6.2.1 Brief Summary of Adverse Events

Treatment-emergent adverse events (TEAEs), regardless of causality, thatoccurred during the study period were reported in 33.1% (118/356) of allpatients, and treatment-related TEAEs were reported in 9.8% (35/356) ofall patients (Table 6-1).

Following twice-daily dosing, 32.6% (44/135) of the Oxy-treated patientsand 43.2% (19/44) of the vehicle-treated patients had TEAEs, and 12.6%(17/135) of the Oxy-treated patients and 11.4% (5/44) of thevehicle-treated patients had treatment-related TEAEs. The proportions ofpatients reporting TEAEs and treatment-related TEAEs were similar acrossthe 3 Oxy twice-daily treatment groups.

Following once-daily dosing, 33.8% (45/133) of the Oxy-treated patientsand 22.7% (10/44) of the vehicle-treated patients had TEAEs, and 9.8%(13/133) of the Oxy-treated patients and 0% (0/44) of thevehicle-treated patients had treatment-related TEAEs. The proportions ofpatients reporting TEAEs and treatment-related TEAEs were slightlyhigher in the Oxy 1.50% QD group than the Oxy 1.0% and 0.5% QD groups.

Across all treatment groups, the most commonly reported TEAEs (occurringin ≥2% patients overall) included headache, contact dermatitis, upperrespiratory tract infection, application site papules, application siteerythema, and application site acne.

There were no deaths reported during the study. There were 5 seriousadverse events reported in 3 patients (1 Oxy 1.0% BID, 1 Oxy 1.0% QD,and 1 vehicle); none of these was considered to be related to studytreatment. One patient (in the vehicle group) discontinued the study dueto serious adverse events.

A total of 2.8% (10/356) of patients discontinued the study due toTEAEs: 8 patients treated with oxymetazoline (2 Oxy 1.5% BID, 3 Oxy 1.0%BID, and 1 each in the Oxy 0.5% BID, Oxy 1.0% QD, and Oxy 0.5% QDtreatment groups) and 2 patients treated with vehicle. The mostfrequently reported adverse events leading to study discontinuation wereapplication site adverse events, all of these events occurred inOxy-treated patients and were considered by the investigator to betreatment-related.

Treatment-related application site adverse events were reported in 28oxymetazoline-treated patients (7 Oxy 1.5% BID, 4 Oxy 1.0% BID, 5 Oxy0.5% BID, 6 Oxy 1.5% QD, 3 Oxy 1.0% QD, and 3 Oxy 0.5% QD) and 5vehicle-treated patients (Table 6-4). A majority of the events were mildor moderate in severity and resolved without sequelae. Seven patients(all treated with oxymetazoline) discontinued from the study due totreatment-related application site adverse events.

TABLE 6-1 Overall Rates of Treatment-emergent Adverse Events (SafetyPopulation) Number (%) of Patients Oxy Oxy Oxy Oxy Oxy Oxy 1.5% 1.0%0.5% Vehicle 1.5% 1.0% 0.5% BID BID BID BID QD QD QD Adverse EventCategory (N = 45) (N = 45) (N = 45) (N = 44) (N = 44) (N = 44) (N = 45)All adverse events 16 (35.6) 12 (26.7) 16 (35.6) 19 (43.2) 20 (45.5) 10(22.7) 15 (33.3) Treatment-related adverse  7 (15.6)  5 (11.1)  5 (11.1) 5 (11.4)  6 (13.6) 4 (9.1) 3 (6.7) events Serious adverse events 0(0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) Discontinuationsdue to 2 (4.4) 3 (6.7) 1 (2.2) 1 (2.3) 0 (0.0) 1 (2.3) 1 (2.2) adverseevents Number (%) of Patients Vehicle Total Oxy Total Oxy Total Total QDBID QD Oxy Vehicle Total Adverse Event Category (N = 44) (N = 135) (N =133) (N = 268) (N = 88) (N = 356) All adverse events 10 (22.7) 44 (32.6)45 (33.8) 89 (33.2) 29 (33.0) 118 (33.1) Treatment-related adverse 0(0.0) 17 (12.6) 13 (9.8)  30 (11.2) 5 (5.7) 35 (9.8) events Seriousadverse events 1 (2.3) 1 (0.7) 1 (0.8) 2 (0.7) 1 (1.1)  3 (0.8)Discontinuations due to 1 (2.3) 6 (4.4) 2 (1.5) 8 (3.0) 2 (2.3) 10 (2.8)adverse events BID = twice daily; Oxy = oxymetazoline hydrochloride; QD= once daily Note: Treatment-emergent adverse events include allreported events that began during the study or increased in severitycompared with baseline. Treatment-related adverse events include thosethat in the investigator's opinion may have been caused by the studymedication with reasonable possibility. Within each preferred term, apatient is counted at most once.6.2.2 All Adverse Events

TEAEs were reported in 33.1% (118/356) of all patients during the studyperiod. TEAEs that were reported in ≥2 patients in any treatment groupare provided in Table 6-2.

Following twice-daily dosing, 32.6% (44/135) of the Oxy-treated patientsand 43.2% (19/44) of the vehicle-treated patients had TEAEs. Theproportions of patients were similar across the Oxy treatment groups,with 35.6%, 26.7%, and 35.6% of patients reporting TEAEs in the Oxy1.5%, 1.0%, and 0.5% BID groups, respectively.

Following once-daily dosing, 33.8% (45/133) of the Oxy-treated patientsand 22.7% (10/44) of the vehicle-treated patients had TEAEs. There wasan higher proportion of patients reporting TEAEs with Oxy 1.5% QD(45.5%) than Oxy 1.0% and 0.5% QD (22.7% and 33.3%, respectively).

Across all treatment groups, the most commonly reported TEAE washeadache in 4.8% (17/356) of patients. Headache occurred in a similarproportion of patients treated with oxymetazoline (4.9% [13/268]) andvehicle (4.5% [4/88]). Two patients (both in the Oxy 1.5% BID group) hadheadache that was considered by the investigator to be related to studytreatment.

Other commonly reported TEAEs (occurring in ≥2% patients overall)included: application site dermatitis in 2.5% (9/356) of all patients,contact dermatitis in 2.2% (8/356) of all patients; upper respiratorytract infection in 2.5% (9/356) of patients; and application sitepapules, application site erythema, and application site acne, eachoccurring in 2.0% (7/356) of all patients. Contact dermatitis wasreported in 2.6% (7/268) of Oxy-treated patients and 1.10% (1/88) ofvehicle-treated patients. The incidence of upper respiratory tractinfection was similar across all treatment groups. Application sitedermatitis, application site papules, and application site erythema werereported only in the Oxy treatment groups. Application site acneoccurred in 1.5% (4/268) of Oxy-treated patients and 3.4% (3/88) ofvehicle-treated patients.

TABLE 6-2 Treatment-emergent Adverse Events Occurring in ≥2 Patients inAny Randomized Treatment Group (Safety Population) Number (%) ofPatients Oxy Oxy Oxy Oxy Oxy Oxy 1.5% 1.0% 0.5% Vehicle 1.5% 1.0% 0.5%System Organ BID BID BID BID QD QD QD Class Preferred Term (N = 45) (N =45) (N = 45) (N = 44) (N = 44) (N = 44) (N = 45) Overall 16 (35.6) 12(26.7) 16 (35.6) 19 (43.2) 20 (45.5) 10 (22.7) 15 (33.3)Gastrointestinal Overall 1 (2.2) 1 (2.2) 3 (6.7) 3 (6.8) 1 (2.3) 0 (0.0)1 (2.2) disorders Vomiting 0 (0.0) 0 (0.0) 0 (0.0) 2 (4.5) 0 (0.0) 0(0.0) 0 (0.0) General Overall  8 (17.8) 4 (8.9)  5 (11.1)  7 (15.9)  8(18.2)  6 (13.6) 4 (8.9) disorders and Application site 2 (4.4) 3 (6.7)1 (2.2) 0 (0.0) 0 (0.0) 3 (6.8) 0 (0.0) administration dermatitis siteconditions Application site 2 (4.4) 0 (0.0) 2 (4.4) 0 (0.0) 2 (4.5) 1(2.3) 0 (0.0) papules Application site 2 (4.4) 0 (0.0) 1 (2.2) 0 (0.0) 1(2.3) 1 (2.3) 2 (4.4) erythema Application site 1 (2.2) 1 (2.2) 0 (0.0)0 (0.0) 2 (4.5) 1 (2.3) 0 (0.0) pruritus Application site 1 (2.2) 0(0.0) 0 (0.0) 3 (6.8) 1 (2.3) 1 (2.3) 1 (2.2) acne Application site 1(2.2) 0 (0.0) 0 (0.0) 0 (0.0) 2 (4.5) 0 (0.0) 0 (0.0) paraesthesiaInfections and Overall 4 (8.9) 1 (2.2) 2 (4.4) 4 (9.1) 4 (9.1) 2 (4.5) 4(8.9) infestations Upper 2 (4.4) 1 (2.2) 1 (2.2) 1 (2.3) 1 (2.3) 1 (2.3)1 (2.2) respiratory tract infection Nasopharyngitis 2 (4.4) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Bronchitis 0 (0.0) 0 (0.0) 0 (0.0)1 (2.3) 0 (0.0) 0 (0.0) 2 (4.4) Investigations Overall 3 (6.7) 1 (2.2) 3(6.7) 3 (6.8) 1 (2.3) 1 (2.3) 0 (0.0) Electro- 1 (2.2) 0 (0.0) 2 (4.4) 0(0.0) 0 (0.0) 1 (2.3) 0 (0.0) cardiogram T wave inversionMusculoskeletal Overall 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3) 2 (4.5) 1 (2.3)1 (2.2) and connective Arthralgia 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2(4.5) 1 (2.3) 0 (0.0) tissue disorders Nervous Overall  5 (11.1) 4 (8.9)1 (2.2)  5 (11.4) 1 (2.3) 2 (4.5)  5 (11.1) system Headache 4 (8.9) 3(6.7) 1 (2.2) 3 (6.8) 0 (0.0) 1 (2.3) 4 (8.9) disorders Migraine 1 (2.2)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (4.5) 0 (0.0) Dizziness 0 (0.0) 0(0.0) 0 (0.0) 2 (4.5) 0 (0.0) 0 (0.0) 0 (0.0) Respiratory, Overall 0(0.0) 2 (4.4) 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) 0 (0.0) thoracic andRhinitis 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)mediastinal seasonal disorders Skin and Overall 3 (6.7) 0 (0.0) 4 (8.9)0 (0.0) 1 (2.3) 1 (2.3) 2 (4.4) subcutaneous Dermatitis 2 (4.4) 0 (0.0)1 (2.2) 0 (0.0) 1 (2.3) 1 (2.3) 2 (4.4) tissue disorders contact Number(%) of Patients Vehicle Total Oxy Total Oxy Total Total System Organ QDBID QD Oxy Vehicle Total Class Preferred Term (N = 44) (N = 135) (N =133) (N = 268) (N = 88) (N = 356) Overall 10 (22.7) 44 (32.6) 45 (33.8)89 (33.2) 29 (33.0) 118 (33.1)  Gastrointestinal Overall 0 (0.0) 5 (3.7)2 (1.5) 7 (2.6) 3 (3.4) 10 (2.8)  disorders Vomiting 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 2 (2.3) 2 (0.6) General Overall 0 (0.0) 17 (12.6) 18(13.5) 35 (13.1) 7 (8.0) 42 (11.8) disorders and Application site 0(0.0) 6 (4.4) 3 (2.3) 9 (3.4) 0 (0.0) 9 (2.5) administration dermatitissite conditions Application site 0 (0.0) 4 (3.0) 3 (2.3) 7 (2.6) 0 (0.0)7 (2.0) papules Application site 0 (0.0) 3 (2.2) 4 (3.0) 7 (2.6) 0 (0.0)7 (2.0) erythema Application site 0 (0.0) 2 (1.5) 3 (2.3) 5 (1.9) 0(0.0) 5 (1.4) pruritus Application site 0 (0.0) 1 (0.7) 3 (2.3) 4 (1.5)3 (3.4) 7 (2.0) acne Application site 0 (0.0) 1 (0.7) 2 (1.5) 3 (1.1) 0(0.0) 3 (0.8) paraesthesia Infections and Overall 3 (6.8) 7 (5.2) 10(7.5)  17 (6.3)  7 (8.0) 24 (6.7)  infestations Upper 1 (2.3) 4 (3.0) 3(2.3) 7 (2.6) 2 (2.3) 9 (2.5) respiratory tract infectionNasopharyngitis 0 (0.0) 2 (1.5) 0 (0.0) 2 (0.7) 0 (0.0) 2 (0.6)Bronchitis 0 (0.0) 0 (0.0) 2 (1.5) 2 (0.7) 1 (1.1) 3 (0.8)Investigations Overall 1 (2.3) 7 (5.2) 2 (1.5) 9 (3.4) 4 (4.5) 13 (3.7) Electro- 1 (2.3) 3 (2.2) 1 (0.8) 4 (1.5) 1 (1.1) 5 (1.4) cardiogram Twave inversion Musculoskeletal Overall 1 (2.3) 0 (0.0) 4 (3.0) 4 (1.5) 2(2.3) 6 (1.7) and connective Arthralgia 0 (0.0) 0 (0.0) 3 (2.3) 3 (1.1)0 (0.0) 3 (0.8) tissue disorders Nervous Overall 2 (4.5) 10 (7.4)  8(6.0) 18 (6.7)  7 (8.0) 25 (7.0)  system Headache 1 (2.3) 8 (5.9) 5(3.8) 13 (4.9)  4 (4.5) 17 (4.8)  disorders Migraine 0 (0.0) 1 (0.7) 2(1.5) 3 (1.1) 0 (0.0) 3 (0.8) Dizziness 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)2 (2.3) 2 (0.6) Respiratory, Overall 3 (6.8) 2 (1.5) 1 (0.8) 3 (1.1) 3(3.4) 6 (1.7) thoracic and Rhinitis 2 (4.5) 0 (0.0) 0 (0.0) 0 (0.0) 2(2.3) 2 (0.6) mediastinal seasonal disorders Skin and Overall 1 (2.3) 7(5.2) 4 (3.0) 11 (4.1)  1 (1.1) 12 (3.4)  subcutaneous Dermatitis 1(2.3) 3 (2.2) 4 (3.0) 7 (2.6) 1 (1.1) 8 (2.2) tissue disorders contactBID = twice daily; Oxy = oxymetazoline hydrochloride; QD = once dailyNote: Treatment-emergent adverse events include all reported events thatbegan during the study or increased in severity compared with baseline,regardless of relationship to treatment. Within each combination ofpreferred term and system organ class, a patient was counted at mostonce.

Additional post hoc analyses were conducted to evaluate adverse eventsthat occurred during treatment period and posttreatment period. Adverseevents during the treatment period included all reported events thatbegan during the study or increased in severity during the treatmentperiod of the study compared with baseline, regardless of relationshipto treatment. Adverse events during the posttreatment period includedall reported events that began on day 29 or after, or increased inseverity compared with the same adverse events reported prior to day 29,regardless of relationship to treatment.

Adverse events during the treatment period were reported in 27.2%(97/356) of all patients: 26.7% (36/135) of the Oxy-treated patients and34.1% (15/44) of the vehicle-treated patients following twice-dailydosing, and 28.6% (38/133) of the Oxy-treated patients and 18.2% (8/44)of the vehicle-treated patients following once-daily dosing. A majorityof the adverse events reported during the treatment period wereconsidered to be of mild or moderate severity.

Adverse events were reported in 7.9% (28/356) of all patients during theposttreatment period: 7.4% (10/135) of the Oxy-treated patients and11.4% (5/44) of the vehicle-treated patients following twice-dailydosing, and 8.3% (11/133) of the Oxy-treated patients and 4.5% (2/44) ofthe vehicle-treated patients following once-daily dosing. Applicationsite events included 1 case of application site scab in the vehicle BIDtreatment group, and 1 case each of application site acne, applicationsite papules, and application site dermatitis in the Oxy once-dailytreatment group. All of the adverse events reported during theposttreatment period were considered to be of mild or moderate severity,with the exception of severe arthralgia and severe headache reported inthe Oxy 1.0% QD group.

6.2.3 Treatment-Related Adverse Events

6.2.3.1 all Treatment-Related Adverse Events

Treatment-related TEAEs (ie, TEAEs that, in the investigator's opinion,may have been caused by the study medication) were reported in 9.8%(35/356) of all patients (Table 6-3).

Following twice-daily dosing, 12.6% (17/135) of the Oxy-treated patientsand 11.4% (5/44) of the vehicle-treated patients had treatment-relatedTEAEs. The proportions of patients were similar across the Oxy treatmentgroups, with 15.6%, 11.1%, and 11.1% of patients reportingtreatment-related TEAEs in the Oxy 1.5%, 1.0%, and 0.5% BID groups,respectively.

Following once-daily dosing, 9.8% (13/133) of the Oxy-treated patientsand 0% (0/44) of the vehicle-treated patients had treatment-relatedTEAEs. There was an increased proportion of patients reportingtreatment-related TEAEs with increasing Oxy doses: 13.6%, 9.1%, and 6.7%of patients in the Oxy 1.5%, 1.0%, and 0.5% QD groups, respectively.

The most frequently reported treatment-related TEAEs were applicationsite events; these are discussed further in Section 6.2.3.2.

TABLE 6-3 All Treatment-related Treatment-emergent Adverse Events(Safety Population) Number (%) of Patients Oxy Oxy Oxy Oxy Oxy Oxy 1.5%1.0% 0.5% Vehicle 1.5% 1.0% 0.5% System Organ BID BID BID BID QD QD QDClass Preferred Term (N = 45) (N = 45) (N = 45) (N = 44) (N = 44) (N =44) (N = 45) Overall  7 (15.6)  5 (11.1)  5 (11.1)  5 (11.4)  6 (13.6) 4(9.1) 3 (6.7) Cardiac Overall 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 1(2.3) 1 (2.2) disorders Supraventricular 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0)0 (0.0) 0 (0.0) 1 (2.2) extrasystoles Atrioventricular 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) block first degree Eye disordersOverall 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Dry eye1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) GastrointestinalOverall 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)disorders Nausea 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)General Overall  7 (15.6) 4 (8.9) 4 (8.9)  5 (11.4)  6 (13.6) 3 (6.8) 3(6.7) disorders and Application site 2 (4.4) 3 (6.7) 1 (2.2) 0 (0.0) 0(0.0) 1 (2.3) 0 (0.0) administration dermatitis site conditionsApplication site 2 (4.4) 0 (0.0) 2 (4.4) 0 (0.0) 2 (4.5) 0 (0.0) 0 (0.0)papules Application site 1 (2.2) 1 (2.2) 0 (0.0) 0 (0.0) 2 (4.5) 1 (2.3)0 (0.0) pruritus Application site 1 (2.2) 0 (0.0) 1 (2.2) 1 (2.3) 1(2.3) 1 (2.3) 1 (2.2) pain Application site 1 (2.2) 0 (0.0) 1 (2.2) 0(0.0) 0 (0.0) 1 (2.3) 2 (4.4) erythema Application site 1 (2.2) 0 (0.0)0 (0.0) 3 (6.8) 0 (0.0) 1 (2.3) 1 (2.2) acne Application site 1 (2.2) 0(0.0) 0 (0.0) 0 (0.0) 2 (4.5) 0 (0.0) 0 (0.0) paraesthesia Applicationsite 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) drynessApplication site 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) 0 (0.0) 0 (0.0)perspiration Application site 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.3) 0(0.0) 0 (0.0) warmth Application site 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 1 (2.2) irritation Investigations Overall 1 (2.2) 1 (2.2)1 (2.2) 0 (0.0) 0 (0.0) 1 (2.3) 0 (0.0) Electro- 1 (2.2) 0 (0.0) 1 (2.2)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) cardiogram T wave inversion Electro- 0(0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) cardiogram T waveamplitude decreased Electro- 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1(2.3) 0 (0.0) cardiogram T wave biphasic Nervous system Overall 2 (4.4)0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) disorders Headache 2(4.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Skin and Overall 0(0.0) 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) subcutaneous Skinlesion 0 (0.0) 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) tissuedisorders Vascular Overall 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) disorders Hypertension 0 (0.0) 1 (2.2) 0 (0.0) 0 (0.0) 0(0.0) 0 (0.0) 0 (0.0) Number (%) of Patients Vehicle Total Oxy Total OxyTotal Total System Organ QD BID QD Oxy Vehicle Total Class PreferredTerm (N = 44) (N = 135) (N = 133) (N = 268) (N = 88) (N = 356) Overall 0(0.0) 17 (12.6) 13 (9.8)  30 (11.2) 5 (5.7) 35 (9.8)  Cardiac Overall 0(0.0) 1 (0.7) 2 (1.5) 3 (1.1) 0 (0.0) 3 (0.8) disorders Supraventricular0 (0.0) 1 (0.7) 1 (0.8) 2 (0.7) 0 (0.0) 2 (0.6) extrasystolesAtrioventricular 0 (0.0) 0 (0.0) 1 (0.8) 1 (0.4) 0 (0.0) 1 (0.3) blockfirst degree Eye disorders Overall 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0(0.0) 1 (0.3) Dry eye 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3)Gastrointestinal Overall 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3)disorders Nausea 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3) GeneralOverall 0 (0.0) 15 (11.1) 12 (9.0)  27 (10.1) 5 (5.7) 32 (9.0) disorders and Application site 0 (0.0) 6 (4.4) 1 (0.8) 7 (2.6) 0 (0.0) 7(2.0) administration dermatitis site conditions Application site 0 (0.0)4 (3.0) 2 (1.5) 6 (2.2) 0 (0.0) 6 (1.7) papules Application site 0 (0.0)2 (1.5) 3 (2.3) 5 (1.9) 0 (0.0) 5 (1.4) pruritus Application site 0(0.0) 2 (1.5) 3 (2.3) 5 (1.9) 1 (1.1) 6 (1.7) pain Application site 0(0.0) 2 (1.5) 3 (2.3) 5 (1.9) 0 (0.0) 5 (1.4) erythema Application site0 (0.0) 1 (0.7) 2 (1.5) 3 (1.1) 3 (3.4) 6 (1.7) acne Application site 0(0.0) 1 (0.7) 2 (1.5) 3 (1.1) 0 (0.0) 3 (0.8) paraesthesia Applicationsite 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3) dryness Applicationsite 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.1) 1 (0.3) perspirationApplication site 0 (0.0) 0 (0.0) 1 (0.8) 1 (0.4) 0 (0.0) 1 (0.3) warmthApplication site 0 (0.0) 0 (0.0) 1 (0.8) 1 (0.4) 0 (0.0) 1 (0.3)irritation Investigations Overall 0 (0.0) 3 (2.2) 1 (0.8) 4 (1.5) 0(0.0) 4 (1.1) Electro- 0 (0.0) 2 (1.5) 0 (0.0) 2 (0.7) 0 (0.0) 2 (0.6)cardiogram T wave inversion Electro- 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0(0.0) 1 (0.3) cardiogram T wave amplitude decreased Electro- 0 (0.0) 0(0.0) 1 (0.8) 1 (0.4) 0 (0.0) 1 (0.3) cardiogram T wave biphasic Nervoussystem Overall 0 (0.0) 2 (1.5) 0 (0.0) 2 (0.7) 0 (0.0) 2 (0.6) disordersHeadache 0 (0.0) 2 (1.5) 0 (0.0) 2 (0.7) 0 (0.0) 2 (0.6) Skin andOverall 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3) subcutaneousSkin lesion 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1 (0.3) tissuedisorders Vascular Overall 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1(0.3) disorders Hypertension 0 (0.0) 1 (0.7) 0 (0.0) 1 (0.4) 0 (0.0) 1(0.3) BID = twice daily; Oxy = oxymetazoline hydrochloride; QD = oncedaily Note: Treatment-emergent adverse events include all reportedevents that began during the study or increased in severity comparedwith baseline. Treatment-related adverse events include those that inthe investigator's opinion may have been caused by the study medicationwith reasonable possibility. Within each preferred term, a patient iscounted at most once.6.2.3.2 Treatment-Related Application Site Adverse Events

This section summarizes application site adverse events that, in theinvestigator's opinion, may have been caused by the study medication.

Treatment-related application site adverse events were reported in 28oxymetazoline-treated patients (7 Oxy 1.5% BID, 4 Oxy 1.0% BID, 5 Oxy0.5% BID, 6 Oxy 1.5% QD, 3 Oxy 1.0% QD, and 3 Oxy 0.5% QD) and 5vehicle-treated patients. These events included application sitedermatitis, application site erythema, application site pruritus,application site pain (burning), application site paresthesia,application site warmth, application site papules, application siteirritation, application site acne, application site dryness, applicationsite perspiration, and skin lesion. A tabular listing of these patientsis provided in Table 6-4.

A majority of the events were mild or moderate in severity and resolvedwithout sequelae; only 4 of these events were ongoing at study exit. Atotal of 7 severe events occurred in 3 Oxy-treated patients; theseincluded severe dermatitis in 1 patient treated with Oxy 1.0% BID;severe pruritus, erythema, and pain (ie, burning) in 1 patient treatedwith Oxy 1.0% QD; and severe pain (ie, burning), irritation, anderythema in 1 patient treated with Oxy 0.5% QD (patient discontinuedfrom the study).

Seven patients (all treated with oxymetazoline) discontinued from thestudy due to treatment-related application site adverse events (Table6-4). All of these events resolved without sequelae upon discontinuationof study treatment.

TABLE 6-4 Patients with Treatment-related Application Site AdverseEvents (Safety Population) Resulted in Study/ Age/ Onset SeveritySerious Treatment Patient Sex/ Preferred Term Day/ Onset/ AdverseDiscon- Number Race^(a) (Investigator Term) Duration^(b) Maximum Event?tinuation? Outcome Oxy 1.5% BID Treatment Group 10001-1003 53/F/CApplication site paraesthesia  2/20 Mild/Mild No No Resolved withoutsequelae (Tingling at application site) 10011-1236 54/F/C Applicationsite pain 2/3 Mild/Mild No No Resolved without sequelae (Facial stingingat application site) 10012-1078 36/F/H Application site pruritus 2/4Mild/Moderate No Yes Resolved without sequelae (Itching at applicationsite) Application site erythema 3/3 Mild/Moderate No Yes Resolvedwithout sequelae (Erythema [irritant reaction] in site of aftertreatment with topical study drug) fluocinonide Application sitedermatitis 3/3 Mild/Moderate No Yes Resolved without sequelae (Sandpapertype rash = irritant after treatment with topical dermatitis in thestudy medication fluocinonide application site of the face) Applicationsite acne 3/3 Mild/Moderate No Yes Resolved without sequelae (Closedcomedones, white heads on after treatment with topical study medicationsite of the face) fluocinonide 10012-1508 36/F/H Application sitepapules  4/13 Mild/Mild No No Resolved without sequelae (Papules atapplication site) 10013-1168 48/F/C Application site dermatitis 7/8Mild/Moderate No Yes Resolved with sequelae (Contact dermatitis faceapplication after treatment with topical site) hydrocortisone 10016-129648/F/C Application site dryness 20/16 Mild/Mild No No Resolved withoutsequelae (Facial dryness at application site) 10016-1401 50/F/CApplication site papules  3/35 Mild/Mild No No Resolved without sequelae(Worsening of facial papules at application site) Oxy 1.0% BID TreatmentGroup 10012-1440 54/M/C Application site pruritus 6/8 Mild/Mild No NoResolved without sequelae (Itching on forehead after application ofstudy product) 10014-1200 38/F/C Application site dermatitis 3/8Moderate/ No Yes Resolved without sequelae (Contact dermatitis - facetreatment area) Severe after treatment with oral diphenhydramine andtopical triamcinolone 10017-1193 51/F/C Application site dermatitis 3/3Moderate/ No Yes Resolved without sequelae (Contact dermatitis to theapplication Moderate after treatment with oral site) diphenhydramine10017-1305 44/F/C Application site dermatitis  7/23 Moderate/ No YesResolved without sequelae (Contact dermatitis at application site)Moderate after treatment with topical hydrocortisone Oxy 0.5% BIDTreatment Group 10002-1012 38/F/C Skin lesion 1/2 Mild/Mild No NoResolved without sequelae (Increased number of inflammatory lesions onthe face [in the application area]) 10012-1079 60/F/H Application sitepapules  8/23 Mild/Mild No No Resolved without sequelae (Papules on drugapplication site) 10012-1158 27/F/H Application site papules  2/18Mild/Mild No No Resolved without sequelae (Papular dermatitis onforehead - drug application site) 10013-1353 23/F/C Application sitedermatitis  6/10 Mild/Mild No No Resolved without sequelae (Contactdermatitis - face application site) 10016-1391 50/F/C Application siteerythema  4/29 Mild/Mild No No Resolved without sequelae (Worsening offacial erythema at application site) Application site pain  4/26Mild/Mild No No Resolved without sequelae (Burning when applying IP[treatment area]) Oxy 1.5% QD Treatment Group 10001-1332 76/M/CApplication site paraesthesia  2/13 Mild/Mild No No Resolved withoutsequelae (Tingling, face [cheeks] at application site) 10012-1146 23/F/HApplication site papules   43/NA Moderate/ No No Ongoing at study exit(Worsening of papules - on study drug Moderate application site of face)10002-1188 42/F/C Application site pruritus  5/16 Moderate/ No NoResolved without sequelae (Pruritus on face [on the treatment area])Moderate 10013-1184 41/F/C Application site pruritus 14/1  Moderate/ NoNo Resolved without sequelae (Itching at application site) ModerateApplication site pain 14/1  Mild/Mild No No Resolved without sequelae(Burning at application site) Application site warmth 15/1  Mild/Mild NoNo Resolved without sequelae (Warm sensation to face at applicationsite) 10013-1250 53/F/C Application site paraesthesia  3/12 Mild/Mild NoNo Resolved without sequelae (Tingling sensation to face applicationsite) 10017-1427 53/F/C Application site papules 15/15 Mild/Mild No NoResolved without sequelae (Increased papules to face at applicationsite) Oxy 1.0% QD Treatment Group 10011-1249 52/F/C Application siteacne 9/9 Mild/Mild No No Resolved without sequelae (Acne at applicationsite) 10012-1167 63/M/C Application site pruritus 2/3 Mild/Severe No NoResolved without sequelae (Pruritus at application site) Applicationsite erythema 2/3 Mild/Severe No No Resolved without sequelae (Erythemaat application site) Application site pain 2/3 Mild/Severe No NoResolved without sequelae (Burning at application site) 10013-123760/F/C Application site dermatitis 4/7 Mild/Mild No Yes Resolved withoutsequelae (Contact dermatitis face application site) Oxy 0.5% QDTreatment Group 10001-1048 38/F/C Application site acne    8/NAMild/Moderate No No Ongoing at study exit (Facial acne - at applicationsite) 10012-1073 56/M/C Application site pain 6/3 Severe/Severe No YesResolved without sequelae (Burning sensation in application site ofstudy drug) Application site irritation 6/3 Severe/Severe No YesResolved without sequelae (Irritation in application site of study drug)Application site erythema 6/3 Severe/Severe No Yes Resolved withoutsequelae (Erythema in application site of study drug) 10012-1345 52/F/CApplication site erythema  8/25 Moderate/ No No Resolved withoutsequelae (Rebound redness at application site 10 Moderate hourspostdose) Vehicle Treatment 10001-1310 56/F/C Application site pain 3/1Moderate/ No No Resolved without sequelae (Stinging/burning, face atapplication Moderate site) 10004-1240 53/F/C Application siteperspiration 15/15 Mild/Mild No No Resolved without sequelae (Facialsweating [at application site]) 10005-1308 23/F/C Application site acne  15/NA Mild/Mild No No Ongoing at study exit (Acne involving site/areaof medication application) 10008-1364 63/M/C Application site acne  15/NA Moderate/ No No Ongoing at study exit (Acne - forehead;treatment area) Moderate 10012-1147 48/F/H Application site acne  1/29Mild/Mild No No Resolved without sequelae (Acne - inflammatory lesionsat application site) BID = twice daily; C = Caucasian; F = female; H =Hispanic; M = male; NA = not applicable; Oxy = oxymetazolinehydrochloride; QD = once daily ^(a)Age in years ^(b)Onset Day = Numberof days since the first dose of study medication. Duration = Number ofdays the adverse event lasted.6.2.4 Subgroup Analyses of Adverse Events

The incidence of TEAEs was analyzed by age group (<45, 45 to 64, and ≥65years of age) and sex (male versus female).

The overall incidence of TEAEs was similar across the Oxy and vehicletreatment groups following twice-daily and once-daily dosing for the agegroups of <45 years and 45 to 64 years. There were too few patients inthe age group of ≥65 years to provide any meaningful conclusions.

The overall incidence of TEAEs was similar across the Oxy and vehicletreatment groups following twice-daily and once-daily dosing for bothmales and females.

6.3 Deaths, Other Serious Adverse Events, and Other Significant AdverseEvents

6.3.1 Deaths

There were no deaths reported in this study.

6.3.2 Other Serious Adverse Events

There were 5 serious adverse events reported in 3 patients during thestudy: 1 event in 1 patient in the Oxy 1.0% BID group, 1 event in 1patient in the Oxy 1.0% QD group, and 3 events in 1 patient in thevehicle QD group. None of these was considered to be related to studytreatment. Serious adverse events that occurred in 1 patient in thevehicle group led to study discontinuation. Brief summaries of thesecases are provided below.

-   -   Patient 10015-1270, a 50-year-old Caucasian female randomized to        the Oxy 1.0% BID treatment group, experienced a serious adverse        event of cerebrovascular accident on day 29 of study drug        administration. The patient had slurred speech and memory        fuzziness starting on day 29. Her symptoms improved in 24 hours        however, she didn't feel right during the following week. On day        39, the patient was hospitalized with a diagnosis of        cerebrovascular accident. She was treated the next day with        acetylsalicylic acid and simvastatin. The patient was discharged        the same day with resolution of the cerebrovascular accident        with sequelae of memory changes. The adverse event was        considered to be mild in severity, not considered to be related        to study medication, and did not result in study        discontinuation.    -   Patient 10012-1167, a 63-year-old Caucasian male with a medical        history of left anterior cruciate ligament (ACL) injury and ACL        surgery, was randomized to the Oxy 1.0% QD group. The patient        experienced a serious adverse event of chondrocalcinosis        pyrophosphate (pseudogout) in the left knee on posttreatment        day 42. The subject had surgery on his left knee 2 days later,        and was administered methylprednisolone sodium succinate for        swelling, and further treatment with oral prednisone. The        patient was discharged the next day with resolution without        sequelae of the chondrocalcinosis pyrophosphate. The adverse        event was considered to be mild to moderate in severity, not        considered to be related to study medication, and did not result        in study discontinuation.    -   Patient 10001-1052, a 66-year-old Caucasian female with a        medical history of right rotator cuff pain, was randomized to        the vehicle QD group. She experienced the serious adverse events        of rotator cuff syndrome on day 19 and hypertension and        congestive heart failure on day 23. The patient was hospitalized        on day 22 for surgical repair of the worsening right rotator        cuff pain. After surgery, her blood pressure increased to 140/70        mm Hg, and she was tachypneic and hypoxic. She was immediately        admitted to the heart failure service and was placed on positive        pressure ventilator. She was diagnosed with hypertension and        congestive heart failure believed to be due to fluid overload        during the surgery. The hypertension improved during her        admission and she was normotensive at discharge. All 3 events        were not considered to be related to study medication, resulted        in study discontinuation, and resolved without sequelae within 6        days.        6.3.3 Discontinuations Due to Adverse Events

A total of 10 of the 356 enrolled patients (2.8%) discontinued thetreatment and study due to adverse events: 8 patients treated withoxymetazoline (2 Oxy 1.5% BID, 3 Oxy 1.0% BID, and 1 each in the Oxy0.5% BID, Oxy 1.0% QD, and Oxy 0.5% QD treatment groups) and 2 patientstreated with vehicle.

The most frequently reported adverse events leading to treatment/studydiscontinuation were application site adverse events; all of theseevents occurred in 7 Oxy-treated patients and were considered by theinvestigator to be treatment-related. These events included applicationsite dermatitis, application site acne, application site erythema,application site pruritus, application site irritation, and applicationsite pain; see Section 6.2.3.2 for further details.

Non-application site adverse events leading to treatment/studydiscontinuation were reported in 5 patients (3 Oxy-treated and 2vehicle-treated patients [some of these patients also reportedapplication site events leading to discontinuation]). These eventsincluded cardiac failure congestive, dry eye, nausea, irritable bowelsyndrome, weight decreased, blood pressure increased, rotator cuffsyndrome, headache, and hypertension.

One patient (10001-1052 [in the vehicle group]) had serious adverseevents that led to study discontinuation; this patient is summarized inSection 6.3.2.

6.4 Clinical Laboratory Evaluation

Laboratory data for each patient were collected, along with the normalranges for each laboratory test. These listings also identify patientswith laboratory values that were abnormal. An abnormal laboratory valuewas defined as one that was higher or lower than the normal range.

For each laboratory test, individual patient changes were evaluatedusing shift tables. These tables include the number of patients whosetest values changed from normal, low, or high (relative to the normalrange) at baseline to normal, low, or high at each follow-up assessment.Laboratory evaluations are presented in the sections below.

A total of 7 patients had adverse events that were considered to berelated to laboratory variables. These included: increased alanineaminotransferase in 2 patients in the Oxy 1.5% BID group; anemia in 2patients in the Oxy 1.0% BID group; hyperkalemia in 1 patient in the Oxy1.0% BID group; hyperglycemia in 1 patient in the Oxy 1.5% QD group; andhematuria in 1 patient in the Oxy 1.0% QD group. All of these eventswere mild in severity, not considered to be treatment-related, and didnot result in study discontinuation.

6.4.1 Hematology

6.4.1.1 Laboratory Values Over Time

Mean laboratory values for hematology variables at baseline were similaramong the treatment groups. Mean changes from baseline at days 29 and56/exit were small and not considered to be clinically relevant.

6.4.1.2 Individual Patient Changes

Most patients had normal hematology values at baseline and days 29 and56/exit. Shift tables of hematology variables were made. A fewindividual patients had values that shifted from normal to abnormal (outof reference range values) in most treatment groups at days 29 and56/exit, but no clinically relevant trends were noted for these shifts.

6.4.1.3 Individual Clinically Significant Abnormalities

A by-patient listing of abnormal hematology values, defined as anyvalues outside the reference range, was made.

6.4.2 Chemistry

6.4.2.1 Laboratory Values Over Time

Mean laboratory values for chemistry variables at baseline were similaramong the treatment groups. Mean changes from baseline at days 29 and56/exit were small and not considered to be clinically relevant.

6.4.2.2 Individual Patient Changes

Most patients had normal chemistry values at baseline and days 29 and56/exit. Shift tables of chemistry variables were made. A few individualpatients had values that shifted from normal to abnormal (out ofreference range values) in most treatment groups at days 29 and 56/exit,but no clinically relevant trends were noted for these shifts.

6.4.2.3 Individual Clinically Significant Abnormalities

A by-patient listing of abnormal chemistry values, defined as any valuesoutside the reference range, was made.

6.4.3 Urinalysis

6.4.3.1 Laboratory Values Over Time

Mean laboratory values for urinalysis variables at baseline were similaramong the treatment groups. Mean changes from baseline at days 29 and56/exit were small and not considered to be clinically relevant.

6.4.3.2 Individual Patient Changes

Most patients had normal urinalysis values at baseline and days 29 and56/exit. Shift tables of urinalysis variables were made. A fewindividual patients had values that shifted from normal to abnormal (outof reference range values) in most treatment groups at days 29 and56/exit, but no clinically relevant trends were noted for these shifts.

6.4.3.3 Individual Clinically Significant Abnormalities

A by-patient listing of abnormal urinalysis values, defined as anyvalues outside the reference range, was made.

6.5 Vital Signs, Physical Findings, and Other Observations Related toSafety

6.5.1 Vital Signs

Mean systolic blood pressure, diastolic blood pressure, respiratoryrate, pulse rate, and body temperature at screening were similar amongthe treatment groups. There were no clinically relevant differencesbetween the treatment groups in the mean change from study baseline forany of the vital signs variables. Although there were some minordifferences in mean values between treatment groups at some visits,there were no signs of any consistent trend from visit to visit and themajority of the observed differences were not considered to beclinically relevant.

6.5.2 Physical Examination

The number of patients with abnormal physical examination findings atscreening and study exit were generally similar between the treatmentgroups for each body system. As expected, a majority of the findings inall treatment groups were coded to SOC of Skin and Subcutaneous TissueDisorders and included rosacea. No safety concerns were evident fromphysical examination findings.

6.5.3 Facial Dermal Tolerability

The proportion of patients with at least a 1-grade increase (worsening)in severity for facial dermal tolerability (ie, dryness, scaling,stinging/burning, and pruritus at the application area) from baseline ondays 1, 14, and 28 is provided in Table 6-5.

All oxymetazoline doses and vehicle treatments given twice-daily oronce-daily were well-tolerated. The proportions of patients withworsening in severity for all 4 tolerability assessments were similarbetween the Total Oxy groups and the Total Vehicle groups followingtwice-daily or once-daily dosing on days 1, 14, and 28.

Following twice-daily or once-daily dosing on day 1, the highestproportions of patients in the Total Oxy treatment groups reported aworsening of stinging/burning at the application site (10.4% in theTotal Oxy twice-daily group and 12.8% in the Total Oxy once-dailygroup). Over time on days 14 and 28, the proportions of patients withworsening of stinging/burning decreased to 8.9% and 1.5% in the TotalOxy twice-daily group on days 14 and 28, respectively, and 12.0% and6.0% in the Total Oxy once-daily group on days 14 and 28, respectively.

TABLE 6-5 Number (%) of Patients with at Least 1-grade Increase(Worsening) in Severity for Dermal Tolerability from Baseline on Days 1,14, and 28 (Safety Population) Number (%) of Patients Twice-daily DosingOnce-daily Dosing Oxy 1.5% Oxy 1.0% Oxy 0.5% Total Oxy Vehicle Oxy 1.5%Oxy 1.0% Oxy 0.5% Total Oxy Vehicle BID BID BID BID BID QD QD QD QD QDDay Dermal Tolerability (N = 45) (N = 45) (N = 45) (N = 135) (N = 44) (N= 44) (N = 44) (N = 45) (N = 133) (N = 44) 1 Dryness 4 (8.9)   5 (11.1)3 (6.7)  12 (8.9)  7 (15.9)  5 (11.4) 6 (13.6) 3 (6.7) 14 (10.5) 4 (9.1)Scaling 2 (4.4)  2 (4.4) 1 (2.2)  5 (3.7) 4 (9.1)  2 (4.5) 2 (4.5)  2(4.4) 6 (4.5) 1 (2.3) Stinging/Burning 8 (17.8) 3 (6.7) 3 (6.7)  14(10.4) 4 (9.1)  4 (9.1) 7 (15.9)  6 (13.3) 17 (12.8) 1 (2.3) Itching(Pruritus) 4 (8.9)   5 (11.1) 3 (6.7)  12 (8.9)  2 (4.5)  4 (9.1) 3(6.8)   7 (15.6) 14 (10.5) 3 (6.8) 14 Dryness 12 (26.7)  11 (24.4) 8(17.8) 31 (23.0) 11 (25.0)  15 (34.1) 10 (22.7)   7 (15.6) 32 (24.1)  9(20.5) Scaling 8 (17.8) 10 (22.2) 9 (20.0) 27 (20.0) 8 (18.2) 14 (31.8)9 (20.5) 11 (24.4) 34 (25.6)  9 (20.5) Stinging/Burning 5 (11.1) 2 (4.4)5 (11.1) 12 (8.9)  9 (20.5)  6 (13.6) 5 (11.4)  5 (11.1) 16 (12.0) 3(6.8) Itching (Pruritus) 8 (17.8)  7 (15.6) 9 (20.0) 24 (17.8) 6 (13.6) 9 (20.5) 9 (20.5) 4 (8.9) 22 (16.5)  7 (15.9) 28 Dryness 6 (13.3)  7(15.6) 9 (20.0) 22 (16.3) 9 (20.5) 10 (22.7) 11 (25.0)   6 (13.3) 27(20.3)  6 (13.6) Scaling 5 (11.1)  6 (13.3) 8 (17.8) 19 (14.1) 10(22.7)  11 (25.0) 6 (13.6) 4 (8.9) 21 (15.8)  5 (11.4) Stinging/Burning2 (4.4)  0 (0.0) 0 (0.0)  2 (1.5) 6 (13.6) 3 (6.8) 2 (4.5)  3 (6.7) 8(6.0) 3 (6.8) Itching (Pruritus) 1 (2.2)  4 (8.9) 9 (20.0) 14 (10.4) 3(6.8)   5 (11.4) 5 (11.4) 1 (2.2) 11 (8.3)   8 (18.2) BID = twice daily;Oxy = oxymetazoline hydrochloride; QD = once daily Note: Severity scale:0 = none, 1 = mild, 2 = moderate, 3 = severe. Timepoints used on day 1were predose, hours 1, 2, 4, 6, 8, 10, and 12. Baseline was the predosemeasurement on day 1. At least a 1-grade increase at any timepoint wasconsidered worsening in the tolerability response.6.5.4 Clinician Telangiectasia Assessment

The CTA was the investigator's assessment of the average overallseverity of telangiectasia on the application sites of the patient'sface.

Frequency distributions of each CTA response category are provided fordays 1, 28, and 56/study exit in Table 6-6, and for other specifiedtimepoints on screening and days 1, 14, 28, 29, 35, and 56/study exit.Frequency distributions of each CTA category were similar across alltreatment groups at all specified timepoints. The proportions ofpatients with moderate telangiectasia (CTA category 3) and severetelangiectasia (CTA category 4) were similar across all treatment groupson day 1 (predose), day 28 (hour 12 postdose), and day 56/exit(posttreatment period), and did not increase over time in any treatmentgroup (Table 6-6). The proportions of patients with severetelangiectasia remained low in each treatment group (ie, ≤5 patients pergroup) at most specified timepoints.

TABLE 6-6 Number (%) of Patients in Each Clinical TelangiectasiaAssessment Response Category on Days 1, 28, and 56 (Safety Population)Number (%) of Patients Twice-daily Dosing Once-daily Dosing Oxy 1.5% Oxy1.0% Oxy 0.5% Vehicle Oxy 1.5% Oxy 1.0% Oxy 0.5% Vehicle BID BID BID BIDQD QD QD QD Day Response (N = 45) (N = 45) (N = 45) (N = 44) (N = 44) (N= 44) (N = 45) (N = 44) 1 0  7 (15.6)  5 (11.1) 4 (8.9) 3 (6.8)  5(11.4)  6 (13.6) 1 (2.2) 3 (6.8) (Predose) 1  9 (20.0) 17 (37.8)  9(20.0) 11 (25.0)  9 (20.5) 10 (22.7) 11 (24.4)  8 (18.2) 2 13 (28.9) 10(22.2) 11 (24.4) 21 (47.7) 14 (31.8) 16 (36.4) 16 (35.6) 16 (36.4) 3 16(35.6)  9 (20.0) 19 (42.2)  7 (15.9) 12 (27.3) 11 (25.0) 15 (33.3) 11(25.0) 4 0 (0.0) 4 (8.9) 2 (4.4) 2 (4.5) 4 (9.1) 1 (2.3) 2 (4.4)  6(13.6) 28 0  7 (15.6)  7 (15.6)  7 (15.6)  8 (18.2)  7 (15.9)  6 (13.6)4 (8.9)  5 (11.4) (Hour 12) 1 10 (22.2) 13 (28.9)  8 (17.8) 12 (27.3) 10(22.7) 10 (22.7) 10 (22.2)  7 (15.9) 2 15 (33.3) 15 (33.3) 15 (33.3) 13(29.5) 17 (38.6) 17 (38.6) 19 (42.2) 20 (45.5) 3 12 (26.7)  8 (17.8) 15(33.3) 10 (22.7)  9 (20.5)  9 (20.5) 12 (26.7)  8 (18.2) 4 1 (2.2) 2(4.4) 0 (0.0) 1 (2.3) 1 (2.3) 2 (4.5) 0 (0.0) 4 (9.1) 56 0  5 (11.1)  8(17.8) 4 (8.9) 4 (9.1)  7 (15.9)  6 (13.6) 2 (4.4) 3 (6.8) (Study 1 14(31.1) 17 (37.8)  9 (20.0) 15 (34.1) 10 (22.7) 12 (27.3) 14 (31.1) 11(25.0) Exit) 2 14 (31.1) 12 (26.7) 16 (35.6) 19 (43.2) 18 (40.9) 15(34.1) 18 (40.0) 14 (31.8) 3 11 (24.4)  7 (15.6) 15 (33.3)  5 (11.4)  7(15.9)  8 (18.2)  8 (17.8) 14 (31.8) 4 1 (2.2) 1 (2.2) 1 (2.2) 1 (2.3) 2(4.5) 3 (6.8) 3 (6.7) 2 (4.5) BID = twice daily; Oxy = oxymetazolinehydrochloride; QD = once daily Note: The Clinical TelangiectasiaAssessment scale: 0 = clear skin with no signs of telangiectasia, 1 =almost clear, a few barely visible telangiectasia, 2 = mild, a fewvisible telangiectasia, 3 = moderate, with the presence of clearlyvisible telangiectasia, 4 = severe, with the presence of many visibletelangiectasia.6.5.5 Lesion Count

The mean number of facial lesions was similar across all treatmentgroups on screening and days 1 (baseline), 14, 28, 35 (posttreatmentfollow-up), and 56 (study exit). There was no clinically meaningfulincrease in mean lesion counts over time in any treatment group. Onepatient treated with Oxy 1.5% BID experienced an adverse event of “skinlesion”. The event was mild in severity and resolved without sequelae in2 days with no change in study treatment (see Section 6.2.3.2 and Table6-4).

6.5.6 12-Lead Electrocardiogram Assessment

ECGs were performed at screening, day 1, and day 28 using standardizedequipment and electrode placement. A qualified third party vendor (ERT)interpreted the ECG results and reported the findings as normal,abnormal, or unable to evaluate.

The analysis showed no ECG effect of 1.5%, 1.0% and 0.5% oxymetazolinetopical creams, administered once or twice daily for 28 consecutivedays, on ECG intervals and diagnostic abnormalities. Mean, minimum, andmaximum values for heart rate, PR interval, QRS interval, and QTcFinterval were within the normal physiologic range, and mean, minimum andmaximum changes were clinically unremarkable at all timepoints for alltreatments. Changes in heart rate and PR interval were consistent withthe expected circadian variation. No consistent change was observed forQRS interval, QTcF interval, or diagnostic abnormalities. Given that theECGs were obtained and analyzed using rigorous centralized ECG methods,it was reasonable to conclude that the doses of topical oxymetazolineused in this study did not cause clinically significant ECG effects.

6.5.7 Pregnancy

No patients became pregnant during the study.

6.6 Safety Conclusions

-   -   All 3 doses of oxymetazoline (1.5%, 1.0%, and 0.5%) were        well-tolerated after once-daily or twice-daily application for        up to 28 consecutive days, with TEAEs reported in 33.1%        (118/356) of all patients and treatment-related adverse events        reported in 9.8% (35/356) of patients.    -   The overall incidences of TEAEs and treatment-related TEAEs were        similar across the 3 Oxy twice-daily treatment groups, but        slightly higher in the Oxy 1.5% QD group than the Oxy 1.0% and        0.5% QD groups. Most TEAEs were considered to be of mild or        moderate severity.    -   The most frequently reported TEAEs (in ≥2% of all patients) were        headache, application site dermatitis, contact dermatitis, upper        respiratory tract infection, application site papules,        application site erythema, and application site acne.    -   Treatment-related TEAEs were reported in 28        oxymetazoline-treated patients and 5 vehicle-treated patients.        The most frequently reported treatment-related TEAEs (in >1% of        all patients) were application site events, including        dermatitis, papules, pain (ie, stinging, burning), erythema,        pruritus, and acne. A majority of the events were mild or        moderate in severity and resolved without sequelae. Most of        these application site events (except 4 cases of acne and        papules) were resolved in the 4-week posttreatment follow-up        period.    -   The most frequently reported non-application site TEAE was        headache, which occurred similarly in oxymetazoline-treated        patients and vehicle-treated patients (4.9% and 4.5%,        respectively).    -   A total of 2.8% (10/356) of patients discontinued the study due        to TEAEs (8 oxymetazoline-treated patients and 2 vehicle-treated        patients), the majority of which were due to application site        adverse events, including application site dermatitis,        application site acne, application site erythema, application        site pruritus, application site irritation, and application site        pain.    -   There were no deaths reported during the study. There were 5        serious adverse events reported in 3 patients, none of which        were considered to be related to study treatment.    -   Subgroup analyses demonstrated that the incidence of TEAEs was        similar across the age and sex subgroups.    -   The proportions of patients with worsening in severity of facial        tolerability were similar between oxymetazoline-treated and        vehicle-treated patients following twice-daily or once-daily        dosing on days 1, 14, and 28, demonstrating that all Oxy        treatment groups had an acceptable local tolerability profile.    -   There were no clinically relevant changes from baseline or        differences between treatment groups with respect to laboratory        values, vital signs, and physical examination findings.    -   There was no increase in mean lesion counts or in the        proportions of patients with moderate or severe telangiectasia        in any of the treatment groups during the study or posttreatment        period.    -   There were no clinically relevant ECG findings observed during        the study.        7. Discussion and Overall Conclusions        7.1 Discussion

The primary objective of this multicenter, randomized, double-blind,vehicle-controlled, parallel-group study was to evaluate the safety,efficacy, facial dermal tolerability, and pharmacokinetic profile ofoxymetazoline cream 0.5%, 1.0%, and 1.5% compared to vehicle appliedtopically twice-daily or once-daily in patients with moderate to severefacial erythema associated with rosacea. The primary efficacy endpointwas a composite measure defined as the proportion of patients with atleast a 2-grade improvement on both the CEA and SSA from baseline over a12-hour period measured at hours 2, 4, 6, 8, 10, and 12 on day 28. Thesecondary efficacy measures included improvements in the compositescores at hours 0.5 and 1.0 on day 28. Key safety data included adverseevents, facial tolerability assessments, ECGs, laboratory variables, andvital signs.

A total of 356 patients were randomized into the study and included inthe mITT and safety populations. The treatment groups were evenlydistributed, with 179 patients receiving twice-daily dosing (135 Oxy and44 vehicle), and 177 patients receiving once-daily dosing (133 Oxy and44 vehicle). Patients were well matched between the 8 treatment groupsfor baseline demographic characteristics with no clinically relevantdifferences between treatment groups for age, sex, race, weight, andheight. The mean age of patients was 50.0 years (range 19 to 79 years),and the majority of patients were female (80.1%) and Caucasian (91.3%).

The primary efficacy variable of the proportions of patients with atleast a 2-grade decrease (improvement) from baseline over a 12-hourperiod for both the CEA and SSA on day 28 indicated that oxymetazolinewas significantly more effective than vehicle in reducing the facialerythema associated with rosacea. A statistically significant reductionin facial erythema was demonstrated with the 1.5% and 1.0% doses ofoxymetazoline cream following twice-daily dosing, and with the 1.5%,1.0%, and 0.5% doses of oxymetazoline cream following once-daily dosing,compared with vehicle. The proportions of responders at hour 12 on day28 following twice-daily dosing were 15.6%, 11.10% and 13.3% withoxymetazoline 1.5%, 1.0%, and 0.5%, respectively, compared to 4.5% withvehicle. The proportions of responders following once-daily dosing were13.6%, 13.6%, and 13.3% with oxymetazoline 1.5%, 1.0%, and 0.5%,respectively, compared to 2.3% with vehicle.

Statistically significant differences were observed as early as hours 2and 4 on day 1 for a majority of the oxymetazoline treatment groupscompared with vehicle. The response rates observed on day 28 were higherthan those observed on day 1 for all oxymetazoline treatment groups,with no tachyphylaxis observed during the study.

twice-daily dosing of oxymetazoline did not provide any significantimprovement over once-daily dosing for any of the doses studied.However, a numerically higher response rate was observed foroxymetazoline 1.0% versus 0.5% given once-daily at most timepoints onday 28. The response rate was similar between the oxymetazoline 1.5% and1.0% doses given once-daily.

Statistically significant erythema reduction (as assessed by theinvestigator using the CEA scale) was demonstrated by 1-grade and2-grade improvements in the CEA from baseline on day 28 for the Oxy 1.0%and 0.5% QD treatment groups compared with vehicle. Patient perceptionof treatment benefit (as assessed by the SSA) was demonstrated by1-grade and 2-grade improvements in the SSA from baseline on day 28 forthe Oxy 1.5%, 1.0% and 0.5% QD treatment groups compared with vehicle.

Oxymetazoline 1.5% and 1.0% given twice-daily and once-daily weresignificantly more effective than vehicle in reducing the facial rednessassociated with rosacea, as demonstrated by the proportion of patientswith at least a 2-grade improvement from baseline over a 12-hour periodon day 28 for both the CEA and SSA-2.

During the 4-week posttreatment period, the proportions of patients witha treatment response in the Oxy treatment groups were greater than orsimilar to those in the vehicle treatment groups. There was noclinically meaningful aggravation of facial erythema. There were nopatients with worsening in CEA, SSA, or SSA-2 during this follow-upperiod. No patients had rebound or worsening of erythema during theposttreatment period, as defined by a 1-grade worsening from baseline onboth the CEA and SSA scales and both the CEA and SSA-2 scales.

Subgroup analyses of the primary efficacy variable demonstrated thattreatment with oxymetazoline was efficacious in the reduction oferythema regardless of sex, age, CEA score, or SSA score.

The health outcomes analyses of Symptom Assessment, Impact Assessment,and Satisfaction Assessment suggest appropriate responsiveness tooxymetazoline treatment, with comparable results for the once-daily andtwice-daily dosing regimens.

Data indicates that steady state may have been reached after the secondand third doses for the once-daily and twice-daily groups, respectively.Steady state systemic exposure of oxymetazoline appeared to increaseapproximately dose proportionally following dermal administration of0.5%, 1.0%, and 1.5% oxymetazoline cream. Since oxymetazoline cream wasadministered twice-daily or once-daily continuously for 28 days, theterminal half-life of oxymetazoline was not able to be assessed in thisstudy. Instead, the mean effective half-life of oxymetazoline wasestimated to be between 18 and 28 hours, regardless of once-daily ortwice-daily dosing regimens. Drug accumulation was minimal following aonce-daily dosing regimen. Increased accumulation was observed in thetwice-daily treatment groups, however, the overall systemic exposure wasless than 2-fold higher when compared to the once-daily treatmentgroups. In this study, the pharmacokinetics of oxymetazoline was studiedunder maximum use conditions with a high dose of 1.5% oxymetazoline,more frequent dosing regimen (twice-daily), and administration to theentire face, representing ˜4% body surface area, which is the maximumsurface area to be treated for the indication.

The safety and tolerability analysis of oxymetazoline demonstrated thatall 3 doses were well tolerated when administered once or twice dailyfor up to 28 days. The proportions of patients reporting TEAEs andtreatment-related TEAEs were similar between the oxymetazoline-treatedpatients and vehicle-treated patients. The overall incidences weresimilar across the 3 Oxy twice-daily treatment groups, but slightlyhigher in the Oxy 1.5% QD group than the Oxy 1.0% and 0.5% QD groups.Across all treatment groups, the most commonly reported TEAEs (occurringin ≥2% patients overall) included headache, application site dermatitis,contact dermatitis, upper respiratory tract infection, application sitepapules, application site erythema, and application site acne. MostTEAEs were considered to be of mild or moderate severity, and to berelated to study treatment.

The most frequently reported treatment-related TEAEs (reported in >1% ofall patients) were application site events including dermatitis,papules, pain (ie, stinging, burning), erythema, pruritus, and acne.These occurred more frequently in oxymetazoline-treated patients.However, no clear dose-response was noted for individual preferredterms. A majority of these events were mild or moderate in severity andresolved without sequelae. There were no deaths reported, and 5 seriousadverse events were reported in 3 patients, none of which wereconsidered to be related to study treatment.

The proportions of patients with worsening in severity of facialtolerability were similar between oxymetazoline-treated andvehicle-treated patients following twice-daily or once-daily dosing. Noaggravations in telangiectasia or facial lesions were observed in any ofthe oxymetazoline or vehicle treatment groups during the study or theposttreatment period. There were no clinically relevant differencesbetween treatment groups with respect to laboratory values, vital signs,and physical examination findings. There were no clinically relevant ECGfindings.

7.2 Conclusions

This multicenter, randomized, double-blind, vehicle-controlled,parallel-group study demonstrated that oxymetazoline hydrochloride creamat concentrations of 1.5%, 1.0%, and 0.5% given once daily significantlyreduced the facial erythema associated with rosacea, as assessed by theinvestigator using the CEA and by the patient using the SSA. Astatistically significant reduction in facial erythema was alsodemonstrated with the 1.5% and 1.0% doses of oxymetazoline creamfollowing twice-daily dosing (with the second dose administered 6 hoursafter the first dose); however, no additional treatment benefit wasobserved with twice-daily dosing over once-daily dosing. Allconcentrations of oxymetazoline were well tolerated when administeredonce or twice daily, with the majority of adverse events limited tolocalized dermatological effects.

The following are non-limiting exemplary embodiments:

-   1. A method of treating facial erythema associated with rosacea in a    patient in need of such treatment, comprising topically    administering once daily to the site of erythema on the face of the    patient a pharmaceutical composition comprising 0.5%, 1.0% or 1.5%    oxymetazoline or a pharmaceutically acceptable salt thereof as the    sole active ingredient.-   2. The method of embodiment 1, wherein the pharmaceutical    composition comprises oxymetazoline hydrochloride as the sole active    ingredient.-   3. The method of embodiment 1 or 2, wherein the pharmaceutical    composition is in a form selected from the group consisting of    solutions, gels, lotions, creams, ointments, foams, emulsions,    microemulsions, milks, serums, aerosols, sprays, dispersions,    microcapsules, vesicles and microparticles thereof.-   4. The method of any one of embodiments 1-3, wherein the    pharmaceutical composition is in the form of a cream.-   5. The method of embodiment 4, wherein the pharmaceutical    formulation further comprises methylparaben, propylparaben,    phenoxyethanol, sodium citrate, citric acid, disodium edetate,    butylated hydroxytoluene, lanolin, medium chain triglycerides,    diisopropyl adipate, oleyl alcohol, polyethylene glycol PEG-300,    polyethylene glycol PEG-6, polyethylene glycol PEG-32, glycol    stearate, cetostearyl alcohol, ceteareth-6, stearyl alcohol,    ceteareth-25, and purified water.-   6. A method of treating facial erythema associated with rosacea in a    patient in need of such treatment, comprising topically    administering twice daily to the site of erythema on the face of the    patient a pharmaceutical composition comprising 1.0% S or 1.5%    oxymetazoline or pharmaceutically acceptable salt thereof as the    sole active ingredient.-   7. The method of embodiment 6, wherein the pharmaceutical    composition comprises oxymetazoline hydrochloride as the sole active    ingredient.-   8. The method of embodiment 6 or 7, wherein the pharmaceutical    composition is in a form selected from the group consisting of    solutions, gels, lotions, creams, ointments, foams, emulsions,    microemulsions, milks, serums, aerosols, sprays, dispersions,    microcapsules, vesicles and microparticles thereof.-   9. The method of any one of embodiments 6-8, wherein the    pharmaceutical composition is in the form of a cream.-   10. The method of embodiment 9, wherein the pharmaceutical    formulation further comprises methylparaben, propylparaben,    phenoxyethanol, sodium citrate, citric acid, disodium edetate,    butylated hydroxytoluene, lanolin, medium chain triglycerides,    diisopropyl adipate, oleyl alcohol, polyethylene glycol PEG-300,    polyethylene glycol PEG-6, polyethylene glycol PEG-32, glycol    stearate, cetostearyl alcohol, ceteareth-6, stearyl alcohol,    ceteareth-25, and purified water.-   11. The method of any one of embodiments 6-10, wherein the second    dose is administered about 6 to about 10 hours after the first dose.-   12. The method of embodiment 11, wherein the second dose is    administered about 6 hours after the first dose.-   13. The method of any one of embodiments 1-12, wherein the patient    experiences no rebound or worsening of erythema during any period    post-treatment.-   14. The method of any one of embodiments 1-13, wherein the topical    administration is well tolerated by the patient and results in    limited systemic exposure of the oxymetazoline or a pharmaceutically    acceptable salt thereof.-   15. The method of embodiment 14, wherein the limited systemic    exposure after 28 days of topical administration is less than about    42 picograms/milliliter when 0.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered; less than    about 66 picograms/milliliter when 1.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered; or less    than about 115 picograms/milliliter when 1.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered.-   16. The method of embodiment 5 or 10, wherein the citric acid is    anhydrous.-   17. The method of embodiment 5, 10 or 16, wherein the sodium citrate    is sodium citrate dihydrate.-   18. The method of embodiment 5, 10, 16 or 17, wherein the lanolin is    anhydrous.-   19. The method of embodiment 5, wherein the pharmaceutical    formulation comprises about 0.5% w/w oxymetazoline HCl, about 0.2%    w/w methylparaben, about 0.05% w/w propylparaben, about 0.8% w/w    phenoxyethanol, about 0.3% w/w sodium citrate dihydrate, about    0.219% w/w anhydrous citric acid, about 0.01% w/w disodium edetate,    about 0.05% w/w butylated hydroxytoluene, about 2% w/w anhydrous    lanolin, about 7% w/w/medium chain triglycerides, about 7% w/w    diisopropyl adipate, about 7% w/w oleyl alcohol, about 4% w/w    polyethylene glycol PEG-300, about 8% w/w polyethylene glycol    PEG-6/polyethylene glycol PEG-32/glycol stearate (Tefose-63), about    8% w/w cetostearyl alcohol, about 2% w/w ceteareth-6/stearyl alcohol    (Cremophor A6), about 2% w/w ceteareth-25, and purified water    (q.s.).-   20. The method of embodiment 5 or 10, wherein the pharmaceutical    formulation comprises about 1.0% w/w oxymetazoline HCl, about 0.2%    w/w methylparaben, about 0.05% w/w propylparaben, about 0.8% w/w    phenoxyethanol, about 0.3% w/w sodium citrate dihydrate, about    0.219% w/w anhydrous citric acid, about 0.01% w/w disodium edetate,    about 0.05% w/w butylated hydroxytoluene, about 2% w/w anhydrous    lanolin, about 7% w/w/medium chain triglycerides, about 7% w/w    diisopropyl adipate, about 7% w/w oleyl alcohol, about 4% w/w    polyethylene glycol PEG-300, about 8% w/w polyethylene glycol    PEG-6/polyethylene glycol PEG-32/glycol stearate (Tefose-63), about    8% w/w cetostearyl alcohol, about 2% w/w ceteareth-6/stearyl alcohol    (Cremophor A6), about 2% w/w ceteareth-25, and purified water    (q.s.).-   21. The method of embodiment 5 or 10, wherein the pharmaceutical    formulation comprises about 1.5% w/w oxymetazoline HCl, about 0.2%    w/w methylparaben, about 0.05% w/w propylparaben, about 0.8% w/w    phenoxyethanol, about 0.3% w/w sodium citrate dihydrate, about    0.219% w/w anhydrous citric acid, about 0.01% w/w disodium edetate,    about 0.05% w/w butylated hydroxytoluene, about 2% w/w anhydrous    lanolin, about 7% w/w/medium chain triglycerides, about 7% w/w    diisopropyl adipate, about 7% w/w oleyl alcohol, about 4% w/w    polyethylene glycol PEG-300, about 8% w/w polyethylene glycol    PEG-6/polyethylene glycol PEG-32/glycol stearate (Tefose-63), about    8% w/w cetostearyl alcohol, about 2% w/w ceteareth-6/stearyl alcohol    (Cremophor A6), about 2% w/w ceteareth-25, and purified water    (q.s.).-   22. A stabilized topical cream formulation comprising about 0.5% w/w    oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   23. A stabilized topical cream formulation comprising about 1.0% w/w    oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   24. A stabilized topical cream formulation comprising about 1.5% w/w    oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   25. A stabilized topical cream formulation consisting essentially of    about 0.5% w/w oxymetazoline HCl, about 0.2% w/w methylparaben,    about 0.05% w/w propylparaben, about 0.8% w/w phenoxyethanol, about    0.3% w/w sodium citrate dihydrate, about 0.219% w/w anhydrous citric    acid, about 0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 20/% w/w anhydrous lanolin, about 7%    w/w/medium chain triglycerides, about 7% w/w diisopropyl adipate,    about 7% w/w oleyl alcohol, about 4% w/w polyethylene glycol    PEG-300, about 8% w/w polyethylene glycol PEG-6/polyethylene glycol    PEG-32/glycol stearate (Tefose-63), about 8% w/w cetostearyl    alcohol, about 2% w/w ceteareth-6/stearyl alcohol (Cremophor A6),    about 2% w/w ceteareth-25, and purified water (q.s.).-   26. A stabilized topical cream formulation consisting essentially of    about 1.0% w/w oxymetazoline HCl, about 0.2% w/w methylparaben,    about 0.05% w/w propylparaben, about 0.8% w/w phenoxyethanol, about    0.3% w/w sodium citrate dihydrate, about 0.219% w/w anhydrous citric    acid, about 0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 70/%    w/w oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about    8% w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   27. A stabilized topical cream formulation consisting essentially of    about 1.5%6 w/w oxymetazoline HCl, about 0.2% w/w methylparaben,    about 0.05% w/w propylparaben, about 0.8% w/w phenoxyethanol, about    0.3% w/w sodium citrate dihydrate, about 0.219% w/w anhydrous citric    acid, about 0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   28. A stabilized topical cream formulation consisting of about 0.5%    w/w oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%6    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   29. A stabilized topical cream formulation consisting of about 1.0%    w/w oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   30. A stabilized topical cream formulation consisting of about 1.5%    w/w oxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/w    propylparaben, about 0.8% w/w phenoxyethanol, about 0.3% w/w sodium    citrate dihydrate, about 0.219% w/w anhydrous citric acid, about    0.01% w/w disodium edetate, about 0.05% w/w butylated    hydroxytoluene, about 2% w/w anhydrous lanolin, about 7% w/w/medium    chain triglycerides, about 7% w/w diisopropyl adipate, about 7% w/w    oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%    w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol    stearate (Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/w    ceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w    ceteareth-25, and purified water (q.s.).-   31. A stabilized topical cream formulation as described in any one    of Tables 1, 1a, 1b or 1c in Example 1 above.-   32. A method of treating facial erythema associated with rosacea in    a patient in need of such treatment, comprising topically    administering once daily to the site of erythema on the face of the    patient a stabilized topical cream formulation comprising 0.5%, 1.0%    or 1.5% oxymetazoline HCl as the sole active ingredient, wherein the    stabilized topical cream formulation is as described in any one of    embodiments 25-31.-   33. The method of embodiment 32, wherein the patient experiences no    rebound or worsening of erythema during any period post-treatment.-   34. The method of embodiment 32 or 33, wherein the topical    administration is well tolerated by the patient and results in    limited systemic exposure of the oxymetazoline or a pharmaceutically    acceptable salt thereof.-   35. The method of embodiment 34, wherein the limited systemic    exposure after 28 days of topical administration is less than about    42 picograms/milliliter when 0.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered; less than    about 66 picograms/milliliter when 1.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered; or less    than about 115 picograms/milliliter when 1.5% oxymetazoline or a    pharmaceutically acceptable salt thereof is administered.

A number of references have been cited, the entire disclosures of whichhave been incorporated herein in their entirety for all purposes.

The present invention is not to be limited in scope by the specificembodiments disclosed in the examples which are intended asillustrations of a few aspects of the invention and any embodiments thatare functionally equivalent are within the scope of this invention.Indeed, various modifications of the invention in addition to thoseshown and described herein will become apparent to those skilled in therelevant art and are intended to fall within the scope of the appendedclaims.

What is claimed is:
 1. A method of treating facial erythema associatedwith rosacea in a patient in need of such treatment, comprisingtopically administering once daily to the site of erythema on the faceof the patient a pharmaceutical composition comprising 1.0% w/woxymetazoline hydrochloride thereof as the sole active ingredient,wherein the patient experiences no rebound or worsening of facialerythema post-treatment.
 2. The method of claim 1, wherein thepharmaceutical composition is in a form selected from the groupconsisting of solutions, gels, lotions, creams, ointments, foams,emulsions, microemulsions, milks, serums, aerosols, sprays, dispersions,microcapsules, vesicles and microparticles thereof.
 3. The method ofclaim 2, wherein the pharmaceutical composition is in the form of acream.
 4. The method of claim 3, wherein the topical administration iswell tolerated by the patient and results in limited systemic exposureof the oxymetazoline hydrochloride.
 5. The method of claim 3, whereinthe pharmaceutical formulation further comprises methylparaben,propylparaben, phenoxyethanol, sodium citrate, citric acid, disodiumedetate, butylated hydroxytoluene, lanolin, medium chain triglycerides,diisopropyl adipate, oleyl alcohol, polyethylene glycol PEG-300,polyethylene glycol PEG-6, polyethylene glycol PEG-32, glycol stearate,cetostearyl alcohol, ceteareth-6, stearyl alcohol, ceteareth-25, andpurified water.
 6. The method of claim 3, wherein the pharmaceuticalformulation comprises about 1.0% w/w oxymetazoline HCl, about 0.2% w/wmethylparaben, about 0.05% w/w propylparaben, about 0 8% w/wphenoxyethanol, about 0.3% w/w sodium citrate dihydrate, about 0.219%w/w anhydrous citric acid, about 0.01% w/w disodium edetate, about 0.05%w/w butylated hydroxytoluene, about 2% w/w anhydrous lanolin, about 7%w/w medium chain triglycerides, about 7% w/w diisopropyl adipate, about7% w/w oleyl alcohol, about 4% w/w polyethylene glycol PEG-300, about 8%w/w polyethylene glycol PEG-6/polyethylene glycol PEG-32/glycol stearate(Tefose-63), about 8% w/w cetostearyl alcohol, about 2% w/wceteareth-6/stearyl alcohol (Cremophor A6), about 2% w/w ceteareth-25,and purified water (q.s.).
 7. The method of claim 6, wherein the topicaladministration is well tolerated by the patient and results in limitedsystemic exposure of the oxymetazoline hydrochloride.
 8. The method ofclaim 1, wherein the treatment results in an at least 2-gradeimprovement from baseline on Clinician's Erythema Assessment (CEA)scale, Subject Self-Assessment of Erythema (SSA), or both.
 9. The methodof claim 1, wherein the treatment results in an at least 1-gradeimprovement from baseline on Clinician's Erythema Assessment (CEA)scale, Subject Self-Assessment of Erythema (SSA), or both.
 10. Themethod of claim 1, wherein a median T_(max) after 28 days of topicaladministration is about 10 hours to about 12 hours.
 11. The method ofclaim 1, wherein a mean C_(max) after 28 days of topical administrationis less than about 133.5 pg/mL.
 12. The method of claim 1, wherein thepatient has a mean C_(max) after 28 days of topical administration isless than about 66 pg/mL.
 13. The method of claim 1, wherein the patienthas an AUC₀₋₂₄ post administration of less than about 2042 pg·hr/mL. 14.The method of claim 1, wherein the patient has an AUC₀₋₂₄ postadministration of less than about 1050 pg·hr/mL.
 15. The method of claim1, wherein the facial erythema is persistent facial erythema.
 16. Themethod of claim 1, wherein the patient is an adult.
 17. The method ofclaim 1, wherein the once daily administration is a pea sized amount ofthe pharmaceutical composition.
 18. A method of treating facial erythemaassociated with rosacea in a patient in need of such treatment,comprising topically administering once daily on the face of the patienta pharmaceutical composition comprising 1.0% w/w oxymetazolinehydrochloride thereof as the sole active ingredient, wherein the patientexperiences no rebound or worsening of facial erythema post-treatment.19. The method of claim 18, wherein the pharmaceutical composition istopically administered in a thin layer to cover the entire face avoidingthe eyes and lips.
 20. The method of claim 18, wherein thepharmaceutical composition is a cream further comprising methylparaben,propylparaben, phenoxyethanol, sodium citrate, citric acid, disodiumedetate, butylated hydroxytoluene, lanolin, medium chain triglycerides,diisopropyl adipate, oleyl alcohol, polyethylene glycol PEG-300,polyethylene glycol PEG-6, polyethylene glycol PEG-32, glycol stearate,cetostearyl alcohol, ceteareth-6, stearyl alcohol, ceteareth-25, andpurified water.
 21. The method of claim 20, wherein the cream comprisesabout 1.0% w/w oxymetazoline HCl, about 0.2% w/w methylparaben, about0.05% w/w propylparaben, about 0 8% w/w phenoxyethanol, about 0.3% w/wsodium citrate dihydrate, about 0.219% w/w anhydrous citric acid, about0.01% w/w disodium edetate, about 0.05% w/w butylated hydroxytoluene,about 2% w/w anhydrous lanolin, about 7% w/w medium chain triglycerides,about 7% w/w diisopropyl adipate, about 7% w/w oleyl alcohol, about 4%w/w polyethylene glycol PEG-300, about 8% w/w polyethylene glycolPEG-6/polyethylene glycol PEG-32/glycol stearate (Tefose-63), about 8%w/w cetostearyl alcohol, about 2% w/w ceteareth-6/stearyl alcohol(Cremophor A6), about 2% w/w ceteareth-25, and purified water (q.s.).22. The method of claim 18, wherein the treatment results in an at least2-grade improvement from baseline on Clinician's Erythema Assessment(CEA) scale, Subject Self-Assessment of Erythema (SSA), or both.
 23. Themethod of claim 18, wherein a median T_(max) after 28 days of topicaladministration is about 10 hours to about 12 hours.
 24. The method ofclaim 18, wherein a mean C_(max) after 28 days of topical administrationis less than about 133.5 pg/mL.
 25. The method of claim 18, wherein thepatient has an AUC₀₋₂₄ post administration of less than about 2042pg·hr/mL.
 26. The method of claim 18, wherein the facial erythema ispersistent facial erythema.
 27. The method of claim 18, wherein thepatient is an adult.
 28. A method of treating facial erythema associatedwith rosacea in a patient in need of such treatment, comprisingtopically administering once daily on the face of the patient apharmaceutical composition comprising 1.0% w/w oxymetazolinehydrochloride thereof as the sole active ingredient.
 29. The method ofclaim 28, wherein the pharmaceutical composition is topicallyadministered in a thin layer to cover the entire face avoiding the eyesand lips.
 30. The method of claim 28, wherein the pharmaceuticalcomposition is a cream further comprising methylparaben, propylparaben,phenoxyethanol, sodium citrate, citric acid, disodium edetate, butylatedhydroxytoluene, lanolin, medium chain triglycerides, diisopropyladipate, oleyl alcohol, polyethylene glycol PEG-300, polyethylene glycolPEG-6, polyethylene glycol PEG-32, glycol stearate, cetostearyl alcohol,ceteareth-6, stearyl alcohol, ceteareth-25, and purified water.
 31. Themethod of claim 30, wherein the cream comprises about 1.0% w/woxymetazoline HCl, about 0.2% w/w methylparaben, about 0.05% w/wpropylparaben, about 0 8% w/w phenoxyethanol, about 0.3% w/w sodiumcitrate dihydrate, about 0.219% w/w anhydrous citric acid, about 0.01%w/w disodium edetate, about 0.05% w/w butylated hydroxytoluene, about 2%w/w anhydrous lanolin, about 7% w/w medium chain triglycerides, about 7%w/w diisopropyl adipate, about 7% w/w oleyl alcohol, about 4% w/wpolyethylene glycol PEG-300, about 8% w/w polyethylene glycolPEG-6/polyethylene glycol PEG-32/glycol stearate (Tefose-63), about 8%w/w cetostearyl alcohol, about 2% w/w ceteareth-6/stearyl alcohol(Cremophor A6), about 2% w/w ceteareth-25, and purified water (q.s.).32. The method of claim 28, wherein the treatment results in an at least2-grade improvement from baseline on Clinician's Erythema Assessment(CEA) scale, Subject Self-Assessment of Erythema (SSA), or both.
 33. Themethod of claim 28, wherein a median T_(max) after 28 days of topicaladministration is about 10 hours to about 12 hours.
 34. The method ofclaim 28, wherein a mean C_(max) after 28 days of topical administrationis less than about 133.5 pg/mL.
 35. The method of claim 28, wherein thepatient has an AUC₀₋₂₄ post administration of less than about 2042pg·hr/mL.
 36. The method of claim 28, wherein the facial erythema ispersistent facial erythema.
 37. The method of claim 28, wherein thepatient is an adult.